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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604294
Report Date: 01/25/2023
Date Signed: 01/25/2023 03:45:56 PM


Document Has Been Signed on 01/25/2023 03:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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: 166DATE:
01/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Ana Cruz, Memory Care DirectorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit to address a deficiency observed during the investigation of complaint control number 18-AS-20220922143233.
A review of records indicated on May 24, 2022 at approximately 6:00AM, Resident #1(R1) slipped and hit their head. On May 25, 2022 at 1:45AM, R1 was found on the floor leaning against the wall and reported they slid off the bed. Later that same day at 6:00PM, R1 was found lying on their back after reportedly slipping on the way to the bathroom and again at 10:57PM R1 was found lying down on the floor and could not recall what happened. On May 26, 2022 at 1:15AM, R1 was found lying down on the bathroom floor. Later that morning at 4:22AM, R1 called staff and staff found R1 on the floor with their head leaning against the wall. R1 had a change in condition as evidenced by multiple falls in a short period of time. The facility failed to address a change in R1's condition and to conduct a reassessment for fall precautions.
The following deficiency was cited per Title 22, Division 6 of the California Code of Regulations on the attached LIC809-D.
An exit interview was conducted and a copy of this report was provided along with Appeal Rights as well as LIC811-Confidential Names list.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2023 03:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: LAS VILLAS DEL NORTE
FACILITY NUMBER: 374604294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/08/2023
Section Cited

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Observation of the Resident- The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by:
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The facility stated an inservice will be conducted with all assisted living staff to recognize changes in resident's condition and to report those changes to facility nurses and/or management. Proof of training to be submitted to CCL by POC due date.
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The licensee did not ensure R1 was provided assistance following a change in condition. Based on record review, beginning 5/24/22, R1 experienced 6 falls in less than 48 hours and was not reassessed or placed on fall precautions. This poses a potential threat to the health, safety, and personal rights risk to residents in care.
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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: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
LIC809 (FAS) - (06/04)
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