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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 04/26/2026
Date Signed: 04/26/2026 04:40:39 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
06/09/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250609165814
FACILITY NAME:VISTA DEL LAGO MEMORY CAREFACILITY NUMBER:
374604274
ADMINISTRATOR:MARIE HILLFACILITY TYPE:
740
ADDRESS:1817 AVENIDA DEL DIABLOTELEPHONE:
(760) 741-2888
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:96CENSUS: 95DATE:
04/26/2026
UNANNOUNCEDTIME BEGAN:
07:59 AM
MET WITH:Brianna Garcia TIME COMPLETED:
02:29 PM
ALLEGATION(S):
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Lack of staff supervision resulting in residents engaging in a physical altercation.
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), Physicians Report LIC 602A (dated 09/23/23) Service Plan Report (dated 06/16/25), Medication Administration Record (dated 02/01/25 through 02/28/25), Residence and Care Agreement (dated 06/04/24), Move In Record (dated 06/16/25), Palomar Medical Records (dated 06/09/25) and Unusual Incident/Injury Report LIC 624 (dated 06/11/25), and other pertinent records associated with this complaint. Interviews conducted with Staff #1-#5, Resident #2-#9, and Witness #1.
(Evaluation Report continues on 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-20250609165814
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: Lack of staff supervision resulting in residents engaging in a physical altercation.


The complaint alleges that a lack of supervision led to a physical altercation among residents. It has been reported that Resident #1 (R1) and Resident #2 (R2) were involved in an incident that resulted in (R1) being admitted to the hospital with a closed ankle fracture. Further reports indicate that the altercation occurred in (R1's) room after (R2) entered, resulting in a confrontation. No additional 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) were all complimentary of the staff and expressed that they received adequate care, support and supervision in a responsive manner. (R2) could not recall the incident that occurred on June 08, 2025, with (R1) and denies having any physical altercations. (R2) stated to be on a friendly relationship with (R1).

Resident #1 (R1) was not available for an interview as the resident is currently being treated at Santa Fe Post Acute and did not return calls.

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 validate this allegation. Staff members (S1-S5) expressed care and supervision are priority for all staff. According to (S1-S5), there have been no prior verbal or physical altercations between Residents #1 (R1) and #2 (R2). Both residents are diagnosed with Major Neurocognitive Disorder (NCD) and exhibit behaviors associated with this condition. However, neither requires one-on-one care.

(S5), who was present during the incident, reported that two other staff members, along with (R1) and (R2), immediately responded when they heard yelling and noises coming from (R1's) room. (S5) explained that (R2) wandered into (R1's) room, mistakenly thinking it was (R2’s) own room, and sought to use the bathroom. During this encounter, a verbal and physical altercation occurred, wherein (R1) grabbed (R2) by the arm, prompting (R2) to push (R1), who then fell to the floor. Following the incident, (R1) complained of leg pain and was taken to the hospital.

(S1-S2) disputed claims of a lack of supervision, emphasizing that the facility has adequate staffing, trained personnel, immediate communication via walkie-talkies, and surveillance cameras in place. (S1) detailed the staffing for different shifts: the morning (AM) shift consists of five caregivers, two med-techs, and one nurse; the afternoon (PM) shift includes five caregivers, two med-techs, and one nurse; while the evening (NOC) shift has four caregivers and one med-tech.

(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)
Page: 2 of 3
Control Number 18-AS-20250609165814
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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(S1-S2) outlined their plan for handling staffing shortages, call-outs, and schedule changes affecting supervision. Staff must secure their own coverage when they call out, and any staffing emergencies are managed through agencies like Clipboard Health. Furthermore, all staff members (S1-S5) have confirmed completion of the required 40 hours of in-service and hands-on shadow training related to (NCD).

On April 25, 2026, between 9:30 AM and 04:30 PM, the Department attempted to interview witness members identified as Witness #1 (W1). (W1) was unavailable for an interview as calls went unanswered.

The Department reviewed Resident #1 (R1’s) service file which included Physicians Report LIC 602A (dated 09/23/23) Service Plan Report (dated 06/16/25), Medication Administration Record (dated 02/01/25 through 02/28/25), Residence and Care Agreement (dated 06/04/24), Move In Record (dated 06/16/25), Palomar Medical Records (dated 06/09/25) and Unusual Incident/Injury Report LIC 624 (dated 06/11/25 and it revealed that (R1) is medically evaluated with occasional agitation behavior.

Further review of Resident #2 (R2’s) service file included Physicians Report LIC 602A (dated 06/03/25) Resident Appraisal LIC 603A (dated 06/06/24), Residence and Care Agreement (dated 06/17/24), Move In Record (dated 06/16/24), Unusual Incident/Injury Report LIC 624 (dated 06/11/25 and it revealed that (R2) is medically evaluated with wandering behavior and no aggressive behavior.

Additional analysis of personnel Care Staff Assignments (dated 06/08/25), Personnel Report LIC 500 (dated 04/25/26) and Relias In-Service Training (dated 01/15/26, 02/19/26, 02/20/26 and 04/24/26) revealed confirmation of number of personnel for each work shift and completed mandatory training requirements.

During the visit on April 25 and 26, 2026, the Department identified that the facility promotes the rights and safety of its residents. Posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility.

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)
Page: 3 of 3