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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604274
Report Date: 06/16/2025
Date Signed: 06/16/2025 12:45:49 PM

Document Has Been Signed on 06/16/2025 12:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
374604274
ADMINISTRATOR/
DIRECTOR:		MARIE HILLFACILITY TYPE:
740
ADDRESS:1817 AVENIDA DEL DIABLOTELEPHONE:
(760) 741-2888
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY: 96CENSUS: 94DATE:
06/16/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Administrator, Marie HillTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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On 6/16/2025, Licensing Program Analyst Janette Romero conducted an unannounced case management visit to the facility to follow up on an Unusual Incident/Injury Report (LIC 624) submitted by the facility reporting an incident involving Resident 1 (R1). LPA met with Administrator, Marie Hill who was informed of the purpose of the visit.

The LIC 624 reported the following information. On 2/28/2025, R1 was found in their room with a container of Powdered Chlorine Bleach Cleaner (PCBC). R1 applied the cleaner onto their hand and face and a "small" amount was found in their cup of water. When asked if consumed, R1 initially reported they did and then denied doing so. The facility called an ambulance and R1 insisted on having dinner. R1 ate their dinner in the dining room with no complaints or reports of pain/discomfort. R1 was taken to the hospital via non-emergency medical transport and later returned to the facility with no new findings.

Administrator Hill was interviewed and reported the following information. The disinfectants/cleaning solutions are stored in the locked laundry room inside every housekeeper's locker. The lockers are individually secured with a keyed padlock. When in use, housekeepers transfer the disinfectants/cleaning solutions onto their mobile carts, which also have a locking mechanism to make it inaccessible to the residents in care. Hospital records indicate the correct date of the incident is 2/27/2025 not 2/28/2025. On 2/27/2025, the incident took place as documented in the LIC 624 noted above. Housekeeping Staff 1 (S1) was assigned to clean R1's bedroom. Administrator Hill interviewed S1 regarding the incident and received following information. S1 used the PCBC to clean R1's room. After cleaning R1's room, S1 only secured one (1) PCBC as they did not realize they had two (2) PCBCs in their cart. S1 admitted to accidentally leaving one (1) PCBC unattended in R1's bedroom, which made it accessible to R1.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janette Romero
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/16/2025 12:45 PM - It Cannot Be Edited


Created By: Janette Romero On 06/16/2025 at 10:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA DEL LAGO MEMORY CARE
FACILITY NUMBER: 374604274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2025
Section Cited
CCR
87465(a)(1)

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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Administrator Hill reported the facility will receive training from an outside vendor regarding regulation 87465 Incidental Medical and Dental Care by close of business on 6/18/2025. POC will be emailed to LPA by close of business on 6/20/2025.
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Based on interviews conducted and records reviewed, R1 was observed with a container of powdered chlorine bleach cleaner. R1 applied the cleaner to hand, face, and in their cup of water. When asked if consumed, R1 initially reported they did. The incident report documents R1 was sent to the hospital via non emergency medical transport rather than activating emergency services, which poses a potential health and safety risk to residents in care.
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Type B
06/20/2025
Section Cited
CCR87309(a)

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(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
This poses a potential health and safety risk to residents in care.
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Administrator Hill reported S1 was counseled regarding the incident and terminated on 2/28/2025. LPA observed the facility's Counseling/Disciplinary Notice for S1 noting their termination of employment effective 2/28/2025.
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Based on interviews conducted and records reviewed, the facility failed to secure a powdered cleaning solution by leaving a container unattended and accessible to R1. R1 then applied the cleaner onto their hand, face and in their cup of water. When asked if consumed, R1 initially reported they did. This poses a health and safety risk to residents in care.
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Administrator Hill added the facility conducted an in-service training on 3/3/2025 and 3/13/2025 regarding safety practices for hazardous and potentially toxic substances including cleaning products. LPA reviewed (2) staff sign-in sheets for the reported trainings. POC met.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janette Romero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/16/2025
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Administrator Hill was made aware of the incident when R1 was having dinner. Facility staff measured R1's vital which were not abnormal and R1 did not exhibit any signs of distress. Therefore, the facility arranged for non-emergency medical transportation to the hospital.

During today's visit, LPA toured the facility and observed the 21 ounce containers of PCBC used by housekeepers. LPA also observed the lockers with padlocks, mobile carts with locks, and laundry room which required a keyed fob entry. LPA observed the ounce PCBC container titled, "Cleanser Powerful Cleaning Action with Chlorine Bleach" and warns users to use protective gloves and eye protection as it causes skin, respiratory, and serious eye irritation. LPA reviewed R1's Physician's Report dated 8/27/2024 noting R1 exhibits confusion, is oriented to self only, and does not have the capacity to leave the facility unassisted, manage their own cash resources or medications. During today's visit, no imminent health or safety concerns were observed. Based on the aforementioned, the facility will be cited and civil penalties will be assessed. An exit interview was conducted, and a copy of this report, LIC 809-D, LIC 412FC, and Confidential Names list (LIC 811) were reviewed and provided to Administrator Hill.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janette Romero
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC809 (FAS) - (06/04)
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