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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604274
Report Date: 12/27/2024
Date Signed: 12/27/2024 12:09:02 PM

Document Has Been Signed on 12/27/2024 12:09 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: 88DATE:
12/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Assistant Resident Services Director, Loucida HickersonTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 12/27/2024, Licensing Program Analyst (LPA), Janette Romero conducted an unannounced case management visit to address a deficiency observed relative to the Unusual Incident/Injury Report (LIC 624) submitted by the facility. LPA met with Assistant Resident Services Director (ARSD), Loucida Hickerson who was informed of the purpose of the visit.

On 12/2/2024, the Department received the LIC 624 reporting Staff 1 (S1) was observed intimidating and bullying Resident 1, Resident 2, and Resident 3 at the facility on 11/29/2024. The LIC 624 noted S1 was placed on administrative leave, escorted out of the building, and is not scheduled to return to work in the facility. The LIC 624 added law enforcement was contacted and the facility met all reporting requirements in a timely manner. Written witness statements were also provided to the Riverside Regional Office as well. LPA reviewed video footage inside the facility's common areas and observed S1 kicking, pushing, using profanity, stepping on resident's feet, and snapping a towel in a resident's face. Although the facility took appropriate actions upon learning of the incidents, multiple residents' personal rights were violated and some were physically abused by S1 while in the facility's care. As a result, the facility will be cited. LPA provided ARSD Hickerson with a copy of Title 22, Division 6, Chapter 8 regulation numbers 87468, 87468.1, and 87468.2 which detail residents' personal rights for the facility to keep as reference.


An exit interview was conducted and a copy of this report was reviewed and provided to ARSD Hickerson along with a Confidential Names list (LIC811) and Appeal Rights.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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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Document Has Been Signed on 01/24/2025 10:16 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/23/2025 11:16 AM


Created By: Janette Romero On 12/27/2024 at 11:47 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
RIVERSIDE ASC, 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: 12/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2025
Section Cited
CCR
87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by:
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Licensee reported the facility will conduct an in-service staff training regarding personal rights of all residents and generate a checklist to include documentation of a reference check for new employees. POC due to LPA by close of business by 1/10/2025.
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Based on interviews conducted, records and video footage reviewed, S1 physically and psychologically abused multiple residents on November 25, 2024 and November 29, 2024. This poses a potential health, safety, and personal rights risk to residents in care.
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*This is an amended version of the original report

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
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