374604274-4-26-2026-18-AS-RORN-DU2LDF-20260513083949

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 04/26/2026
Date Signed: 04/26/2026 04:35:45 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
02/06/2025 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20250206113759

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: 95	DATE:	04/26/2026
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Brianna Garcia		TIME COMPLETED:	02:39 PM

ALLEGATION(S):

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Facility staff did not notify resident's representative of a medical procedure conducted on the resident.

INVESTIGATION FINDINGS:

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On April 26, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial, unannounced complaint visit. Brianna Garcia Licensed Vocational Nurse, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above.

The investigation included interviews, inspection of the faciltiy and a collection of records. The Department reviewed several documents, including the Facility Staff Roster (dated 04/25/26 & 06/16/25), Facility Resident Roster (dated 04/25/26 & 06/16/25), Miso Dermatology Authorization and Consent Form (date 07/16/24), Consent for Emergency Medical Treatment, LIC 627 (dated 06/04/24), Physicians Report LIC 602A (dated 05/06/24), Preplacement Appraisal Information LIC 603 (dated 05/30/24), Move In Record (dated 06/13/24), Physicians Order for Life Sustaining Treatment (dated 05/06/24), Declaration of Health Agent (dated 06/04/24), Comfort and Peace Records (dated 01/16/25), and other pertinent records associated with this complaint. Interviews conducted with Staff #1-#5, Resident #2-#9, and Witness #1-#3.
(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2026

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 3

Control Number 18-AS-20250206113759

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: 04/26/2026

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Facility staff did not notify resident's representative of a medical procedure conducted on the resident.

The complaint alleges that the staff at the facility did not inform Resident #1’s (R1) representative about a medical procedure that took place. Specifically, it states that on February 4, 2025, a biopsy was performed on (R1), which required two stitches on (R1’s) lower left back, as reported by the hospice nurse. Additionally, it is claimed that the facility administrator was unaware of this procedure. No further information regarding the allegation has been provided.

On April 25, 2026, between 9:45 AM and 11:59 AM, the Department interviewed resident members identified as Resident #2 through Resident #9 (R2-R9). Eight (8) out of the (8) were unable to support this claim. (R2-R9) appreciated the staff and reported no issues with notifying their representative about medical treatments, procedures, or hospitalization. (R2) shared that staff member #1 (S1) showed kindness by visiting (R2) during a hospital treatment. (S1) offered support and brought personal items during this difficult time.

Resident #1 (R1) was not available for an interview as the resident had passed on April 8, 2025.

On April 25, 2026, between 8:40 AM and 3:35 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members could not corroborate this allegation. Staff members (S1-S5) reported that they are responsible for notifying resident representatives about medical events or procedures. (S1, S2, and S5) stated that a resident's authorized representatives are informed whenever a medical procedure is performed or the resident's condition changes. Specific forms, logs, and communication tools are used for this purpose, including phone calls, voicemails, emails, and written notifications. Additionally, (S1 and S5) indicated that in the case of (R1), the biopsy treatment was performed by Mismo Dermatology, an in-house service provider, who worked with (R1's) authorized representatives to obtain authorization and consent for the treatment.

On February 9, 2026, and April 25, 2026, between 03:30 PM and 04:30 PM, the Department attempted to interview witness members identified as Witness #1 through Witness #3. (W1) was interviewed but decided not to proceed, stating that they are no longer affiliated with Vista Del Lago Memory Care.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2026

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20250206113759

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: 04/26/2026

NARRATIVE

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(W1) thinks that their past connection might not reflect the current situation and could have caused some issues. (W2-W3) were unavailable for interviews as calls went unanswered.

The Department reviewed Resident #1 (R1's) service file which included the Miso Dermatology Authorization and Consent Form (date 07/16/24) it indicated "I hereby authorize and consent to any of the following operation(s) or procedure(s) as deemed medically necessary by the provider": biopsy, liquid nitrogen freezing, local anesthetics, phototherapy, complex wound excision, and other skin procedures. Representative authorization appears in the patient's signature dated 07/16/24. A review of the Consent for Emergency Medical Treatment, LIC 627 (dated 06/04/24) indicated that an authorized representative signed the form. Further review of (R1’s) Physicians Report LIC 602A (dated 05/06/24), Preplacement Appraisal Information LIC 603 (dated 05/30/24), Move In Record (dated 06/13/24), Physicians Order for Life Sustaining Treatment (dated 05/06/24), Declaration of Health Agent (dated 06/04/24), Comfort and Peace Records (dated 01/16/25), Facility Progress Notes (dated 02/5/25 & 02/07/25), Medication Administration Record (dated 02/01/25 through 02/28/25), Miso Dermatology Notes (dated 02/04/25) and Residence and Care Agreement (dated 06/04/24).

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

An exit interview was conducted with Brianna Garcia, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2026

LIC9099 (FAS) - (06/04)

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