374604294-11-19-2024-18-AS-TDAN-DB72LY-20241119163020

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604294
Report Date: 09/19/2023
Date Signed: 11/19/2024 04:27:31 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
05/18/2023 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230518160952

FACILITY NAME:	LAS VILLAS DEL NORTE		FACILITY NUMBER:	374604294
ADMINISTRATOR:	FARISH, JOLENE		FACILITY TYPE:	740
ADDRESS:	1325 LAS VILLAS WAY		TELEPHONE:	(760) 741-1047
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	198	CENSUS: 154	DATE:	09/19/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ana Cruz, Resident Services Director		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Resident is severely neglected
Resident is unsupervised
Resident is not fed regularly

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 Ana Cruz, Resident Services Director and explained the purpose of the visit.
Regarding the allegation "Resident is severely neglected", it was alleged on 5/16/2023, Resident #1 (R1) had been found covered in dried feces. Review of R1's Progress Notes dated 5/16/2023 revealed during rounds, and ten minutes prior to the incident, R1 was observed to be free of feces as they sat in the hallway. Two (2) of six (6) staff interviewed reported R1 had one (1) or two (2) instances of removing feces from their incontinent garment. LPA attempted to interview R1 however, R1 did not verbally respond to LPA's presence or inquires. Interview with R1's responsible party revealed they are happy with the care R1 is provided.
Regarding the allegation "Resident is unsupervised", it was alleged R1 had been found sitting alone without the presence of any staff near them. Six (6) of six (6) staff interviewed revealed residents are checked on at least four (4) times per shift. Three (3) of six (6) staff interviewed reported residents are (CONTINUED ON LIC9099-C) *THIS IS AN AMENDED REPORT

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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

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
05/18/2023 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230518160952

FACILITY NAME:	LAS VILLAS DEL NORTE		FACILITY NUMBER:	374604294
ADMINISTRATOR:	FARISH, JOLENE		FACILITY TYPE:	740
ADDRESS:	1325 LAS VILLAS WAY		TELEPHONE:	(760) 741-1047
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	198	CENSUS: 154	DATE:	09/19/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ana Cruz, Resident Services Director		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Facility does not provide a safe and clean environment for the resident

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 Ana Cruz, Resident Services Director and explained the purpose of the visit.
Regarding the allegation "Facility does not provide a safe and clean environment for the resident", it was alleged that a dirty mattress soiled with "poop and blood" was found to be propped up against the wall in Resident #1's (R1's) bathroom. Six (6) of six (8) staff interviewed reported a mattress utilized by R1's former roommate had somehow been placed in the bathroom for storage. Review of Progress Note dated 5/14/2023 revealed R1 was found in their bathroom sitting on a mattress with a bump forming on their left forehead area. The notes further indicated emergency services were activated as required however, R1 did not require medical intervention. Interview with staff revealed when R1 was found, their left side of their forehead was leaning against the wall. The mattress was not removed from the bathroom until two (2) days later and only after a visitor expressed concerns regarding the mattress as documented in Progress Note dated 5/16/2023. LPA observed the mattress after it had been removed from the bathroom. The mattress was noted to be soiled with a (CONTINUED ON LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 18-AS-20230518160952

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: LAS VILLAS DEL NORTE	FACILITY NUMBER: 374604294
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/20/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities-(a) Residents...shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations, ...and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee will establish a procedure re: how and when furniture is removed from the unit when needed and conduct training of all memory care staff regarding the procedure. Proof of training to be submitted to CCL by 5PM on 9/20/2023.
	8 9 10 11 12 13 14	The licensee did not ensure personal rights were maintained for residents. Based on observations, interviews, and records reviewed, R1 was found injured sitting on top of a mattress stored in their bathroom. This poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 18-AS-20230518160952

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: LAS VILLAS DEL NORTE	FACILITY NUMBER: 374604294
	VISIT DATE: 09/19/2023

NARRATIVE

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(CONTINUED FROM LIC9099-A)
brownish colored stain which was thick enough to be crusted in some areas.
Based on LPA’s observations, interviews conducted, and 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), are being cited on the attached LIC 9099-D.

An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list and Appeal Rights.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 18-AS-20230518160952

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: LAS VILLAS DEL NORTE	FACILITY NUMBER: 374604294
	VISIT DATE: 09/19/2023

NARRATIVE

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(CONTINUED FROM LIC-9099)
checked on every thirty (30) minutes. Review of R1's Physician's Report, Level of Care Assessments, and Progress Notes did not indicate R1 required direct supervision. LPA attempted to interview R1 however, R1 did not verbally respond to LPA's presence or inquires. Interview with R1's responsible party revealed they are happy with the care R1 is provided.
Regarding the allegation "Resident is not fed regularly", it was alleged that R1 was noted to have severe weight loss. Review of R1's Physician's Report dated 8/29/2022 revealed R1 was able to feed themselves. Review of R1's Level of Care Assessment dated 5/12/2023 revealed R1 only required reminders of meal times but did not require assistance with feeding. Review of R1's Weight Record for June 2022 to May, 20, 2023 revealed R1's weight was 146 lbs. on 6/1/2022. R1's weight was noted to be 133 lbs. on 5/20/2023 indicating a weight loss of thirteen (13) pounds in nearly one (1) year's time. The weight record also indicated three (3) separate instances of weight gain following weight loss during that same period. Six (6) of six (6) staff interviewed reported R1 had a good appetite and ate well. LPA attempted to interview R1 however, R1 did not verbally respond to LPA's presence or inquires. Interview with R1's responsible party revealed the food R1 is provided at the facility is very good and that R1 was fed well.
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.

*THIS IS AN AMENDED REPORT

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

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