374604274-3-21-2024-18-AS-TDAN-D5SUZ3-20240531160054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 03/21/2024
Date Signed: 03/21/2024 12:16:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2024 and conducted by Evaluator Sara Martinez

COMPLAINT CONTROL NUMBER: 18-AS-20240129091639

FACILITY NAME:	VISTA DEL LAGO MEMORY CARE		FACILITY NUMBER:	374604274
ADMINISTRATOR:	MARIE HILL		FACILITY TYPE:	740
ADDRESS:	1817 AVENIDA DEL DIABLO		TELEPHONE:	(760) 741-2888
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92029
CAPACITY:	96	CENSUS: 93	DATE:	03/21/2024
		UNANNOUNCED	TIME BEGAN:	10:31 AM
MET WITH:	Executive Director Marie Hill		TIME COMPLETED:	12:28 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff’s lack of supervision resulted in resident sustaining multiple falls and hospitalization
Staff left resident soiled on the floor

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Sara Martinez made an unannounced visit to the facility to deliver findings for the allegation noted above. LPA was granted entry and met with Executive Director Marie Hill and discussed the details pertaining to the complaint.
Regarding the allegation “Staff’s lack of supervision resulted in resident sustaining multiple falls and hospitalization” it was reported Resident One (R1) had fallen multiple times resulting in hospitalization. Record review revealed R1 had four (4) unwitnessed falls on (01/04/2024, 12/14/2023, 12/01/2023, 11/28/2023) and one (1) witnessed fall on 01/03/2024. Falls from 01/04/2024 and 12/14/2023 required R1 to be taken to the hospital. A record review revealed that at the time of all 4 unwitnessed falls there was sufficient staffing with two (2) Med Tech and seven (7) Caregivers during both the AM and PM shifts and four (4) caregivers for overnight. The facility had a total of 89 residents during the time of the incidences noted. Interview with Resident Service Coordinator Priscilla Bermudas revealed R1 was deemed a fall risk and staff are instructed to perform safety checks every 2 hours and R1’s bedroom door is always open so staff can continuously check on R1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 18-AS-20240129091639

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA DEL LAGO MEMORY CARE	FACILITY NUMBER: 374604274
	VISIT DATE: 03/21/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Interview with staff confirmed safety checks were performed for R1 throughout the day and night. There is no clear indication that the facility was not providing proper care and supervision during the time of each unwitnessed falls. Therefore based on interviews and record review, the allegation “Staff’s lack of supervision resulted in resident sustaining multiple falls and hospitalization” has been deemed unsubstantiated at this time.

Regarding the allegation “Staff left resident soiled on the floor” it was reported R1 was left on the floor soiled and does not receive amble care. Interview with R1’s responsible party revealed during the unwitnessed fall on 01/04/2024, R1 had soiled himself and the caregivers who were present during the fall did not assist R1 with cleaning R1 up. Interview with staff revealed most of R1’s falls occurred while ambulating to the bathroom. Staff would observe if R1 had soiled themselves and would assist with changing and cleaning R1 or R1 would request assistance from staff to help clean up. Facility staff notes for R1’s falls do not notate if resident had soiled themselves during the fall. Record review of R1’s file reveals R1 maintains independence and does not require assistance for toileting. R1 requires staff assistance for personal hygiene. Therefore based on the information obtained, there is not enough evidence that staff left resident soiled on the floor. Therefore, the allegation has been deemed unsubstantiated at this time.

Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED.

An exit interview was conducted where a copy of this report was discussed and provided to Executive Director Hill.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2