374604274-7-8-2022-18-AS-RSTS-CZN4ZD-20240119183235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 07/08/2022
Date Signed: 07/08/2022 03:31:58 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/30/2022 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220630115535

FACILITY NAME:	VISTA DEL LAGO MEMORY CARE		FACILITY NUMBER:	374604274
ADMINISTRATOR:	GONZALEZ, JEFF		FACILITY TYPE:	740
ADDRESS:	1817 AVENIDA DEL DIABLO		TELEPHONE:	(760) 741-2888
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92029
CAPACITY:	96	CENSUS: 84	DATE:	07/08/2022
		UNANNOUNCED	TIME BEGAN:	10:47 AM
MET WITH:	Amanda Wolfe, Resident Services Director		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility is not following reporting requirements.
Incidents involving resident in care were not reported to resident's family.
Residents are not being properly supervised while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified himself and discussed the purpose of the visit with Resident Services Director Amanda Wolfe (S1). S1 accompanied LPA on a tour the facility and found that 84 residents are in the facility with approximately 20 staff.

Regarding allegation, "Facility is not following reporting requirements." LPA interviewed S1, and reviewed statements in relation to R1 having contracted COVID-19. Due to conflicting information that was provided by RP and Licensee, it was determined that the allegation be UNSUBSTANTIATED.

Continued on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220630115535

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: VISTA DEL LAGO MEMORY CARE	FACILITY NUMBER: 374604274
	VISIT DATE: 07/08/2022

NARRATIVE

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Regarding allegation, "Incidents involving resident in care were not reported to resident's family." LPA found that through progress notes obtained from Licensee, LPA found that on both falls that R1 sustained, family was contacted and arrived at the facility to evaluate the situation. Thus this allegation was UNSUBSTANTIATED.

Regarding allegation, "Residents are not being properly supervised while in care." LPA found that regarding the statement made by RP, the fall incidents regarding R1 were responded to and treated by facility staff in a timely manner. Also, during the visit, LPA noticed an abundance of staff on the floor and attending to residents in care. Thus, this allegation was deemed UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was discussed with and provided to S1 along with copies of the LIC9099-C, and LIC811.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

LIC9099 (FAS) - (06/04)

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