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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604294
Report Date: 03/22/2022
Date Signed: 03/23/2022 08:29:06 AM



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
07/15/2021 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20210715152600
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: 160DATE:
03/22/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Executive Director, Jolene FarishTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Facility staff did not provide timely medical treatment for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to conclude the complaint investigation. LPA identified herself and discussed the complaint findings with Assistant Executive Director, Lorena Vivar and Executive Director, Jolene Farish.

During the investigation, LPA briefly toured the facility, requested records and interviewed staff, residents, and outside sources. It was alleged facility staff did not provide timely medical treatment for Resident #1 (R1). R1’s Physician’s Report reflected R1 is ambulatory, able to walk without assistance, and able to follow instructions. Facility’s Level of Care Assistance documentation dated 05/19/21 reflected R1 requires assistance with bathing; dressing; medication; and ordering supplies for toileting; requires reminders with grooming; and eating. However, R1 is independent with transfer ability; and transport/escort. It was reported there were two separate incidents involving R1, and the facility did not seek timely medical treatment for either incident. The first incident occurred on 03/27/21. R1 was found on the ground of the patio with injuries at approximately 1:30pm. Facility’s documentation reflected R1 was assessed and 911 was activated. R1 was sent to the hospital at approximately 1:42pm, which was timely medical treatment. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
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-20210715152600
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: 03/22/2022
NARRATIVE
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The second incident occurred on 07/14/21. Facility’s documentation indicated on 07/14/21 at approximately 5:00pm, R1 was observed by staff to be very restless, agitated, and unable to redirect. R1 was also observed by staff leaning towards their right side and unstable while walking; R1 required staff assistance while walking to prevent R1 from falling. On 07/15/21 at 12:44pm the facility contacted R1’s Psychiatrist for direction. The Psychiatrist’s nurse responded at 1:03pm, and recommended contacting R1’s Primary Care Physician (PCP). The facility did not contact the PCP until instructed by the Psychiatrist’s nurse. On 07/15/21, the facility contacted the PCP at approximately 1:03pm but did not receive a return call until 1:48pm. The PCP advised staff to send R1 to the hospital for evaluation. Staff interviews revealed R1’s vitals were taken and there was no urgency to send R1 out for evaluation. Facility’s documentation indicated R1 required medical attention on 07/14/21 when R1 was observed leaning towards the right side and unable to walk unassisted. Facility’s documentation indicated on 07/15/21 at approximately 1:51pm, facility staff activated 911. R1 did not receive medical attention until 07/15/21 at 2:20pm, which was arrival to the hospital.

On 07/15/21, R1 was transported to the hospital via 911, not non-emergency ambulance services, which demonstrated immediate medical attention was needed. At the hospital, R1 was diagnosed with a medical condition and prescribed a new medication. Emergency Department Physician Notes reflected the chief complaint was for right sided weakness and stated, "facility thinks it was around 5:00pm on 07/14/21, does have a facial droop". It also stated R1 had “been leaning to the right when sitting, staff were concerned for mild right facial droop. The symptoms are close to 24 hours since onset.” Facility staff were aware R1 had right sided weakness and unable to walk without assistance but did not send R1 out for evaluation. R1 didn’t receive timely medical treatment until approximately 21 hours after observation of weakness and leaning to their right side, along with facial droop.

Based on documentation and interviews, which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. The facility did not seek timely medical treatment for R1. R1 was not evaluated until approximately 21 hours after observation of weakness and leaning to their right side. California code of Regulations, Title 22, Division 6 & Chapter 8, is being cited on the attached LIC 9099D. [See LIC 811 Confidential Names List to identify Resident #1]. An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20210715152600
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: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2022
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis. This requirement is not met as evidenced by:
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The Executive Director agreed to ensure that all staff receive training, provided by an outside vendor, pertaining to contacting emergency medical services. The Executive Director agreed to provide the date of scheduled training to Community Care Licensing (CCL) by POC due date and
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Based on interviews, the licensee did not contact 911 or obtain emergency medical services for 1 out of 160 residents. This posed an immediate health and safety risk to residents in care.
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provide proof of training to CCL upon completion, which will be scheduled to occur within two weeks.
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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: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
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
07/15/2021 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20210715152600

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: DATE:
03/22/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
11:50 AM
ALLEGATION(S):
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3
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9
Facility does not have sufficient staff to answer telephones
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to conclude the complaint investigation. LPA identified herself and discussed the complaint findings with Executive Director, Jolene Farish.

During the investigation, LPA briefly toured the facility, requested records and interviewed staff, residents, and outside sources. It was alleged, the facility does not have sufficient staffing to answer telephones. It was reported, in July 2021, staff were not answering the phones or returning messages. The facility has a concierge Monday through Friday from 8:00am-4:30pm. If the phone is not answered by the concierge the phone rolls over to an automated voicemail. The voicemail provides direction stating to select the department or a specific individual by pressing the assigned number. Outside source interviews revealed when trying to contact a particular department, such as the memory care unit, there is no answer and voicemails are not returned due to lack of staffing. Staff interviews revealed if staff are unavailable to answer the phone when it rings in memory care, a message can be left. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
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-20210715152600
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: 03/22/2022
NARRATIVE
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Staff indicated they are busy providing care to the residents and are unable to answer the phone each time it rings. However, staff are required to check the voicemail's by the end of their shift and return all voicemail's. Further outside source interviews revealed in 2021, there were some issues with not receiving returned calls, but it was unknown if it was due to lack of staffing. Additional interviews revealed once the facility was aware of the issue, it was rectified, and the facility provided the facility’s nurse’s contact information to families/friends as a resource. A review of the facility’s staffing schedule for July 2021 revealed the facility had sufficient staffing to answer the phones. The facility’s staffing schedule reflected caregivers and medication technicians on all shifts. Staff interviews revealed in addition to the schedule, the facility also had an LVN for the AM/PM shift, lunch, and throughout the NOC shift; and the memory care unit Director who is also an LVN worked 5 days a week and was on call 24/7.

Based on interviews, which were conducted and record review, we have found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred and is therefore determined to be unsubstantiated. An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5