374604274-7-20-2021-08-AS-DPOL-C5FNZF-20210731105417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 07/20/2021
Date Signed: 07/20/2021 10:06:29 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2020 and conducted by Evaluator Evangelica Torres

COMPLAINT CONTROL NUMBER: 08-AS-20201109153935

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: 85	DATE:	07/20/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Resident Service Director, Levina Dubose		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff did not seek medical attention in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Eva Torres conducted a visit to deliver findings on the above allegation. LPA identified herself, spoke with Resident Service Director Levina Dubose, and disclosed the purpose of the visit. The investigation included multiple interviews and a review of records.

It was alleged the facility did not seek medical attention for Resident #1's (R1) (See LIC 811- Confidential Names List for R1) in a timely manner.

On October 16, 2020, R1 was admitted to the facility. The review of R1's records including, but not limited to the Pre-Admission Report dated September 30, 2020, Physician's Report dated October 05, 2020, Plan of Care dated October 16, 2020, and the Reappraisal dated October 16, 2020, showed that R1 required care and supervision due to their cognitive diagnosis with behavioral disturbances. The pre-admission report dated September 30, 2020, showed that R1 needed eight welfare checks per shift, behavior support, escort assistant, prompts for feeding, and assistance with bathing, dressing, grooming, toileting, and medication management.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica Torres	TELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

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 08-AS-20201109153935

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VISTA DEL LAGO MEMORY CARE	FACILITY NUMBER: 374604274
	VISIT DATE: 07/20/2021

NARRATIVE

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The report also indicates that staff would use a wheelchair to transfer R1 in cases of weakness. The physician's report dated October 05, 2020, documented R1 as non-ambulatory and requires assistance with all activities of daily living, which also supports the findings on the pre-admission report date September 30, 2020. On October 16, 2020, the facility conducted a reappraisal of R1's state, of which the appraisal further supports the welfare checks, escort assistant, and assistance with transferring, bathing, toileting, dressing, grooming, and medication management.

LPA also reviewed the facility's records, which included the staff schedules who worked on November 03, 2020, through November 04, 2020, Nursing Notes from November 03, 2020, through November 04, 2020, and its SharePoint's records for November 4, 2020, as the records show an electronic timeline of staff is meeting R1's routine care and welfare checks. The records' review was consistent with the various times' stamps when staff conducted their welfare checks and met R1's needs.

On November 03, 2020, at approximately 03:20 PM, staff #1 (S1) documented that they observed a change in R1 behavior, which was described as R1 eating less, leaning their body forward, of which they were unable to remain straight. S1 assessed R1 by taking their vitals and found their vitals to be within normal limits. Therefore, S1 assisted R1 to bed and documented that they would continue to monitor R1's condition. On November 04, 2020, at approximately 03:00 PM, S2 noticed that R1 was having difficulty breathing. S2 notified S1 and wheelchair R1 to be assessed by S1. S1 assess R1's state and found them to be somewhat unresponsive to verbal cues. S1 recheck R1's vitals and found that R1 had a low-grade fever of 100 degrees. At that time, S1 called 911.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica Torres	TELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20201109153935

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VISTA DEL LAGO MEMORY CARE	FACILITY NUMBER: 374604274
	VISIT DATE: 07/20/2021

NARRATIVE

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In reviewing the hospital's records, it documented R1 arrival at the hospital at 03:16 PM. The records also showed that R1 arrived at the hospital with a fever and shortness of breath. The hospital records further showed that R1's vitals were checked at 03:27 PM, at which their temperature measured at 102.7 degrees. After R1's examination, it was found that R1 contracted a respiratory infection. While in the hospital, R1 was placed on comfort care, which means lifesaving measures were halted so that a person may transition without suffering, as they declined, eventually leading to their passing. On November 05, 2020, at 03:58 PM, R1 passed away while in the hospital with the cause of death documented as Septic Shock due to Pneumonia. LPA also reviewed the Medical Examiner's report, and it did not support the allegation.

Moreover, LPA interviewed staff and their interviews were found to be somewhat consistent with the review of records, as some were unable to recall details of the incidents. LPA was unable to interview R1 due their passing.

Based on interviews conducted and a review of documents, there is insufficient evidence to prove or disprove that the allegation occurred; therefore, the investigation is found to be unsubstantiated. An exit interview was conducted with Resident Service Director Levina Dubose. The Licensee/Appeal Rights (LIC 9058 01/16) and a copy of this report was emailed to them with their signature on the form. A return email or reply receipt from Mrs. Dubose will confirm receipt of documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica Torres	TELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

LIC9099 (FAS) - (06/04)

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