374604274-9-17-2026-18-AS-KBUY-DYELXW-20260930090924

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 09/17/2026
Date Signed: 09/17/2026 09:42:28 AM

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
10/20/2022 and conducted by Evaluator Garrett Haner-Tomasko

COMPLAINT CONTROL NUMBER: 18-AS-20221020110131

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: 94	DATE:	09/17/2026
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator - Marie Hill		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff neglect resulted in resident severe dehydration
Staff are not ensuring resident is being repositioned, resident developed pressure injury while in care
Staff did not assist resident with meal service
Staff did not safeguard residents personal belongings from going missing

INVESTIGATION FINDINGS:

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On 9/17/2026 at 9:00am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to conduct a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Marie Hill and explained the purpose of the visit.

On 10/20/2022, the Riverside Adult and Senior Care Regional Office (RO) originally received this complaint regarding neglect/lack of care and supervision. The complaint alleged that Resident #1 (R1) was severely dehydrated and developed stage two pressure injuries while in care at the facility due to staff neglect and lack of care and supervision. The complaint also included allegations that staff did not assist residents with meal service and staff did not safeguard resident’s personal belongings from going missing.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

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 5

Control Number 18-AS-20221020110131

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: 09/17/2026

NARRATIVE

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On 10/21/2022, from 10:03am to 1:15pm, LPA Arreola conducted an unannounced initial complaint investigation visit to the facility. LPA Arreola met with Executive Director/Administrator at the time, Levina Dubose and explained the reason for the visit. During the visit, the LPA collected documentation for R1 including admissions agreement, physician report, last doctor's visit and lab work, progress notes, the resident's medication administration record (MAR), centrally stored list of medications, and latest care plan. LPA also interviewed the Executive Director.

Additionally, the Department conducted interviews; on 10/31/2022, from approximately 9:00am to 11:20am, with the Administrator Levina Dubose and other staff; on 10/31/2022 at approximately 11:20am, with a witness; and on 4/7/2023 at approximately 11:20am, with Person #1 (P1). In addition, the Department reviewed records from Elizabeth Hospice, Temecula Hospital, the County of Riverside, and facility documents related to the investigation.

On the allegations, staff neglect resulted in resident severe dehydration, staff are not ensuring resident is being repositioned, resident developed pressure injury while in care, and staff did not assist resident with meal service; It was alleged that the facility was serving R1 mechanical soft foods, but staff were not assisting R1 eat their food and when visitors visited R1, R1 was asleep with food still in their mouth. It was also alleged that the neglect of the facility staff led to R1’s rapid decline that led to R1’s transfer to the hospital on 10/1/2022 where R1 was diagnosed with severe dehydration, an electrolyte imbalance, and a stage two pressure injury on their coccyx. R1 passed away in the hospital on 10/9/2022 due to cardiopulmonary arrest.

Review of R1’s physician’s report (LIC602A) dated 8/30/2022 reveals R1’s primary diagnosis as Alzheimer’s disease and secondary diagnosis of palliative care. It also states R1 had dysphagia, requiring a mechanical soft altered texture diet and thin liquids. Hospice records also state R1 was diagnosed with vascular dementia with behavioral disturbance, chronic kidney disease stage 3, anxiety disorder, gastro-esophageal reflux disease, and hypersomnia. Among the medications R1 was prescribed were Seroquel 25mg one tablet every morning, Seroquel 200mg one tablet every night, Zoloft 25mg one tablet daily, and Depakote 250mg one capsule twice daily.

(Continued on LIC9099-C)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 18-AS-20221020110131

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: 09/17/2026

NARRATIVE

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The Department’s review of R1’s hospice records indicate R1 was transferred from one hospice agency to The Elizabeth Hospice agency on 6/20/2022. Subsequently, R1 was admitted to a skilled nursing facility (SNF). The Elizabeth Hospice agency continued to care for R1 during their stay at the SNF and after they moved into this facility on 8/31/2022.

Hospice notes from a visit with R1 at the SNF on 8/30/2022 state R1 needs to be fed, has increased daytime sleep, requires assistance dressing, bathing, grooming, and with incontinence. It also states R1’s skin was intact with no abnormalities noted and that R1’s appetite was fair. Records indicate that a hospice nurse from the agency visited R1 at this facility on 8/31/2022 (the day they were admitted), 9/6/2022, 9/8/2022, 9/15/2022, 9/22/2022, 9/27/2022, and 9/30/2022. On 9/2/2022 hospice ordered clotrimazole cream 1% with z-guard to apply twice daily to affected areas on buttocks and a note from a nurse visit on 9/3/2022 states the cream was ordered due to evidence of skin breakdown, that appeared beefy red to buttocks bilaterally. A hospice aide provided bathing assistance to R1 at the facility on 9/1/2022, 9/8/2022, 9/15/2022, 9/21/2022, 9/28/2022, and 9/30/2022. During the visits on 9/15/2022 and 9/21/2022 the hospice aide noted red areas on R1’s bottom that staff and the hospice nurse were aware of. The facility medication administration records indicate the cream was administered twice daily by staff. Multiple staff interviews revealed that care staff were repositioning R1 frequently throughout the day and using the cream as prescribed. Staff also stated they would get R1 up in a wheelchair, but they would yell out and scream in public spaces and when R1 was in their room in bed they seemed more comfortable.

During a virtual care conference conducted on 9/26/2022 held by hospice staff with facility staff and R1’s family, R1’s care was reviewed, including their inconsistent sleep pattern, decline in food and fluid intake, medications and R1’s wishes for limited treatment and no artificial nutrition. At the care conference the concern of a sore developing in R1’s mouth was also discussed and a hospice physician order stating R1 may have puree diet was provided to the facility.

(Continued on LIC9099-C)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 18-AS-20221020110131

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: 09/17/2026

NARRATIVE

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On 9/27/2022 a hospice nurse conducted an oral check noting R1 to have a skin growth on the roof of their mouth, pinkish in color with no drainage. Staff reported that R1 had 75% of their breakfast that morning and staff stated it did not appear the growth impeded R1’s swallowing. Staff interviews reveal that when R1 moved into the facility they ate and drank with staff assistance, but during the week prior to R1 going to the hospital on 10/1/2026 they appeared to be declining. Hospice records document that on 9/30/2022 staff notified hospice that R1 had not been eating for the last couple of days, spitting their food out, pocketing it in their cheek, and not opening their mouth for more. Staff interviewed reported that R1 would not swallow their food and would keep the food in the pocket of her mouth or spit it out, staff reported they attempted various methods to get R1 to swallow, eat and drink. Interviews also reveal staff were instructed by hospice not to force R1 to eat or drink.

Interviews and record review indicate that on 10/1/2022 R1’s family requested they be sent out 911 due to a continued decline and R1 was transported to Temecula Valley Hospital where they were diagnosed with dehydration. Hospital notes also state R1 had a soft tissue mass in the roof of their mouth, but no open wounds or evidence of intraoral infection. Additionally, a note indicates R1 had an unstageable pressure injury on the midline of their sacrum that was present on admission. A death certificate from the County of Riverside indicates R1 passed at the hospital on 10/9/2022 with an immediate cause of death as cardiopulmonary arrest.

Based on all interviews conducted and documents received, at this time the above allegations were found to be unsubstantiated, meaning that the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred.

On the allegation, staff did not safeguard residents personal belongings from going missing; it was alleged that half of R1’s personal belongings went missing, specifically clothing and shoes. It is alleged that other residents were observed walking around wearing R1’s clothing and that residents would walk into R1’s room and take their belongings. This was allegedly reported to the facility Administrator at the time, Levine Dubose, and the facility did not offer to replace the missing items.

(Continued on LIC9099-C)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 18-AS-20221020110131

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: 09/17/2026

NARRATIVE

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Review of R1’s Admission Agreement states “we will make a reasonable effort to assist residents in maintaining possession and protection of personal items. However, personal items, including but not limited to items of clothing, prescription glasses, dentures or hearing aids, may be lost or misplaced. We shall not be responsible for loss of any personal property, unless such loss or damage was caused by the negligence or intentional misconduct of our employees.” Records reveal that no personal property inventory record for R1’s personal items was completed.

Based on all interviews conducted and documents received, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted, report signed, and report provided to the current Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

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