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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604294
Report Date: 01/25/2023
Date Signed: 01/25/2023 04:14:58 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, 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
09/22/2022 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220922143233
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
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ana Cruz, Memory Care DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not answer the resident's call button in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude a complaint investigation into the allegation list above. LPA met with Memory Care Director Ana Cruz and informed her of the purpose of the visit.
Regarding the allegation "Staff did not answer the resident's call button in a timely manner", it was alleged that on May 14, 2022, Resident #1(R1) activated their call button and waited over thirty(30) minutes for staff to respond. Records reviewed indicated that on May 14, 2022, R1 activated their call button a total of six(6) times. R1's call button activation on May 14, 2022 at 11:06 AM resulted in a staff response time of thirty-five(35) minutes and eleven(11) seconds. R1's call button activation on May 14, 2022 at 2:38 PM resulted in a staff response time of thirty-nine(39) minutes and eleven(11) seconds. R1 could not be interviewed. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with Appeal Rights and LIC811- Confidential Names list.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 18-AS-20220922143233
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
01/25/2023
Section Cited
CCR
87468(a)
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Personal Rights- (a) Residents in residential care facilities for the elderly shall have personal rights...those listed in Sections 87468.1, Personal Rights... and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. This requirement was not met as evidenced by: The Licensee did not ensure
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The facility stated a training was recently conducted with all caregivers which outlined their responsibilities in responding to resident's call lights in a timely manner. Proof of training already received. Deficiency cleared during today's visit.
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resident's call button was answered in a timely manner. Based on records reviewed, 2 of R1's 6 call buttons on 5/14/22 took staff more than 30 minutes to respond. This poses a potential 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
LIC9099 (FAS) - (06/04)
Page: 2 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, 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
09/22/2022 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220922143233

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
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ana Cruz, Memory Care DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained multiple falls due to lack of supervision
Facility staff did not ensure a safe environment for resident
Facility staff did not assist resident with changing clothes
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Memory Care Director Ana Cruz and explained the purpose of today's visit.
Regarding the allegation "Resident sustained multiple falls due to lack of supervision", it was alleged that R1 was not provided proper supervision resulting in R1 experiencing a series of unwitnessed falls in their room the night of May 25, 2022 to May 26, 2022 as well as a previous fall on May 4, 2022. Records reviewed and interviews conducted revealed R1 resided at the facility for twenty-three(23) days and did not require line of sight supervision. The investigation revealed R1 was provided direct staff supervision a minimum of one hundred and twenty-five(125) times through call light activation, medication administration, staff rounds, and/or nurse interactions.
Regarding the allegation "Facility staff did not ensure a safe environment for resident", it was alleged that
R1's walker did not fit through their bathroom doorway due to the width of the bathroom door itself and yet required the walker to safely ambulate while in the bathroom. It was also alleged that the facility made
(CONTINUED ON LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20220922143233
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/25/2023
NARRATIVE
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(CONTINUED FROM LIC9099-C)
an assessment to remove the bathroom door but failed to do so. Records reviewed revealed R1 selected the assigned room prior to admission. Interviews conducted revealed R1 and their family toured their assigned room prior to admission and did not make any mention of R1's walker not fitting through the bathroom door, nor was a mention made that the bathroom door would need to be removed for R1 to use the bathroom safely. Records reviewed also indicated R1 "loved" the room assigned to them. Interviews conducted revealed R1 could ambulate with their walker through the bathroom doorway sideways but not head on. Facilty staff had suggested to R1's family that they add a floor to ceiling mobility pole to R1's bathroom to aide in their safety but this was not done. Facility staff also reminded R1 and their family that staff could be called to provide assistance should R1 want/need to use the bathroom. Interviews conducted also revealed that after assessing the issue, the bathroom door could not be removed due to current fire code requirements.
Regarding the allegation "Facility staff did not assist resident with changing clothes", it was alleged that R1 was wearing the same clothes they had worn to an appointment three(3) days prior because R1 refused to change their clothes. Records reviewed revealed R1 was scheduled to be provided assistance in changing their clothes twice daily. Interviews conducted revealed R1 would often become frustrated with staff assistance in changing clothes and demand to left alone, would refuse assistance in changing clothes entirely, or would completely refuse to change clothes even after receiving encouragement to do so. R1 could not be interviewed.
Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted and a copy of this report was provided along with 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
LIC9099 (FAS) - (06/04)
Page: 4 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, 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
09/22/2022 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220922143233

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
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ana Cruz, Memory Care DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff did not dispense medications as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to conclude an investigation into the allegation listed above. LPA met with Memory Care Director Ana Cruz and explained the purpose of the visit.
Regarding the allegation "Facility staff did not dispense medications as prescribed", it was alleged that the facility failed to follow Resident #1's(R1's) prescription for Alprazolam. It was alleged that R1 should have been given Alprazolam every four hours as prescribed by their physician. Records reviewed indicated R1 had been prescribed Alprazolam 0.5 mg tablet every four hours as needed for anxiety not to exceed 6 doses in a 24 hour period. R1 resided at the facility for twenty-three(23) days and was provided seventy-six(76) doses of Alprazolam during that time all within the prescribed parameters of the prescription. Interviews conducted revealed R1 regularly requested additional Alprazolam immediately following or within a short time frame following taking it. Interviews also revealed R1 required extensive and repeated education regarding the limitations of their prescription. R1 could not be interviewed. This agency has investigated the complaint alleging "Facility staff did not dispense medications as prescribed". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 5 of 5