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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604294
Report Date: 10/27/2022
Date Signed: 10/27/2022 04:02:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/28/2022 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20220128112125
FACILITY NAME:LAS VILLAS DEL NORTEFACILITY NUMBER:
374604294
ADMINISTRATOR:FARISH, JOLENEFACILITY TYPE:
740
ADDRESS:1325 LAS VILLAS WAYTELEPHONE:
(760) 741-1047
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:198CENSUS: 171DATE:
10/27/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Generations Program Director, Ana CruzTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff are not maintaining a clean bathroom for the resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint visit to collect additional records and deliver findings regarding the above-mentioned allegation. The LPA was greeted by Generations Program Director, Ana Cruz identified himself, and disclosed the purpose of the visit.

The Department’s investigation consisted of tours of the facility, review of records, and interviews with internal and external sources.

It was alleged staff did not maintain a clean bathroom for Resident # 1 (R1). An outside source reported multiple visitors had witnessed R1’s bathroom floor to be dirty. An interview with an outside source revealed that on one occasion, R1’s bathroom floor was witnessed to have urine. This outside source reported the dirty floor to staff, spent the next two hours at the facility, and the dirty floor was not addressed by staff. Review of records obtained at the facility revealed staff had witnessed R1 urinating in different places, including hallways, and R1’s bedroom floor.
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
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 08-AS-20220128112125
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: LAS VILLAS DEL NORTE
FACILITY NUMBER: 374604294
VISIT DATE: 10/27/2022
NARRATIVE
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Interviews with internal sources corroborated incidents of unexpected bowel movement resulting in dirty bathroom floors to be common. These internal sources also revealed the facility has had a plan in place to address such incidents when the housekeeping unit was not on site, but these procedures were not always followed, resulting in dirty bathroom floors.

Based on the evidence gathered, the preponderance of evidence standard was met to Substantiate the above allegation. This deficiency was cited in the attached LIC 9099D. A Plan of Correction was jointly discussed and formulated with Generations Program Director, Ana Cruz.

An exit interview was conducted with Generations Program Director, Ana Cruz, to whom a copy of this report, LIC 9099D, and the Licensee Rights (LIC9058 9/16) were provided to via electronic mail. An electronic mail read receipt confirms the documents were received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20220128112125
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: LAS VILLAS DEL NORTE
FACILITY NUMBER: 374604294
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2022
Section Cited
CCR
87303(a)(1)
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87303 Maintenance and Operations (a)
(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. this requirement was not me as evidenced by:
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Generations Program Director agreed to conduct in service training for all staff regarding cleaning and sanitation procedures, by 11/23/2022.
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Based on interviews, the licensee did not ensure florr surfaces were clean and sanitary, which posed a pontential health, safety and personal rights risk to 1 of 171 residents in care.
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Generations Program Director agreed to submit proof of completed trainings and attendance sheet by 11/23/2022.
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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: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/28/2022 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20220128112125

FACILITY NAME:LAS VILLAS DEL NORTEFACILITY NUMBER:
374604294
ADMINISTRATOR:FARISH, JOLENEFACILITY TYPE:
740
ADDRESS:1325 LAS VILLAS WAYTELEPHONE:
(760) 741-1047
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:198CENSUS: 171DATE:
10/27/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Generations Program Director, Ana CruzTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff are not meeting the resident's needs
Staff are not assisting resident with hearing aids
Staff did not safeguard the resident's personal property
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint visit to collect additional records and deliver findings regarding the above-mentioned allegations. The LPA was greeted by Generations Program Director, Ana Cruz, identified himself, and disclosed the purpose of the visit.

The Department’s investigation consisted of tours of the facility, review of records, and interviews with internal and external sources.

It was alleged staff did not meet Resident # 1 (R1) needs. An outside source reported facility staff were not providing regularly scheduled showers, as evidenced by R1 consistently having dirty nails. Interviews with internal sources revealed it was common for residents with dementia to have dirty fingernails, as these residents sometimes attempted to assist themselves with incontinence care.
(See attached LIC 9099C)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20220128112125
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: LAS VILLAS DEL NORTE
FACILITY NUMBER: 374604294
VISIT DATE: 10/27/2022
NARRATIVE
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These sources also revealed staff provided manicures, and additional showers to residents with incontinence, regardless of the level of care and number of weekly showers scheduled. Review of records obtained at the facility did not reveal any concerns with R1 missing, nor refusing showers while at the facility. Additional records corroborated facility management responded to these concerns, and on multiple occasions attempted to schedule a care conference to discuss the appropriate level of care with R1’s responsible party. Review of records, interviews with internal and external sources, corroborated the responsible party did not visit the facility, and did not schedule a care conference.

It was alleged the facility staff were not assisting Resident # 1 (R1) with wearing hearing aids. Interviews with internal sources revealed R1 would often remove the hearing aids and misplace them. Review of records corroborated management had notified R1’s responsible party R1 often attempted to remove the hearing aids and often misplaced them. These records also revealed management notified staff to assist R1 with wearing the hearing aids. An interview with an outside source, who visited R1 on several occasions, confirmed staff had mentioned R1 would consistently remove the hearing aids, and they often went missing.

It was alleged staff did not safeguard Resident # 1 (R1) personal property. An outside source reported R1’s shoes, clothing and hearing aids would often go missing. Interviews with internal sources revealed it was common for residents in the memory care unit, including R1, to wonder and misplace R1’s items. The memory care unit had a protocol in place that required all items to be labeled, prior to the residents moving in. If unlabeled items were found during by the washing and drying process, the laundry department would hold them until the owner was identified. Review of records corroborated R1 had displayed wondering behaviors. An interview with an outside source, who visited R1 on multiple occassions, confirmed facility staff had notified this outside source, R1 would often misplace R1’s hearing aids, or staff would place them in the staff office when R1 was witnessed removing the hearing aids.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did, or did not occur, therefore, the allegations are unsubstantiated.



An exit interview was conducted with Generations Program Director, Ana Cruz, to whom a copy of this report and the Licensee Rights (LIC9058 9/16) were provided to via electronic mail. An electronic mail read receipt confirms the documents were received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5