<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604545
Report Date: 03/07/2025
Date Signed: 03/07/2025 06:33:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/09/2024 and conducted by Evaluator Nacole Patterson
COMPLAINT CONTROL NUMBER: 08-AS-20241209163025
FACILITY NAME:GARDENS AT ESCONDIDOFACILITY NUMBER:
374604545
ADMINISTRATOR:MCBRIDE, FERLINAFACILITY TYPE:
740
ADDRESS:1342 NORTH ESCONDIDO BLVDTELEPHONE:
(760) 480-8155
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:101CENSUS: 68DATE:
03/07/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Resident Services Director Nae BrownellTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee permanently changed resident's accomodations without required notice.
Licensee did not answer communications from a representative promptly.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Resident Services Director Nae Brownell.

On 12/09/2024 it was alleged that Licensee permanently changed a resident's accommodations without required notice and Licensee did not answer communications from a representative promptly. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, outside sources, and LPA direct observations. Regarding the allegation, "Licensee permanently changed resident's accommodations without required notice", it was alleged that a resident was permanently moved to a different room in the facility without the required written 30-day notice to the responsible party. Staff interviews corroborated the allegation, informing that residents on the second floor of the Memory Care unit were moved to the first floor to accommodate the second level being converted to Assisted Living units. (Continued on LIC9099-p.2)
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
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-20241209163025
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GARDENS AT ESCONDIDO
FACILITY NUMBER: 374604545
VISIT DATE: 03/07/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continued from LIC9099 p.1)

Facility management stated that the move was urgent due to the scheduling of the contracted flooring replacements. Management confirmed that verbal notice was provided to all Responsible Parties for the affected residents, however a 30-day written notice was unable to be issued. Staff interviews further revealed that confusion existed among staff and residents/resident families regarding whether the resident moves were temporary or permanent.

Review of facility resident rosters before and after the timeframe of complaint confirmed that the Memory Care residents on the second floor were reassigned to first floor rooms. No records were found to show that the Licensee provided the responsible parties involved the required 30-day written notice. The Residence and Care Agreement states that the facility will provide 30-day written notice to residents if a substitute apartment is necessary for a resident.

Regarding the allegation, "Licensee did not answer communications from a representative promptly", it was alleged that the Licensee did not respond to inquiries, voicemails, or messages left by a responsible party. Staff interviews corroborated the allegation, informing that management staff did not consistently respond to resident families timely. Staff informed having knowledge of family members contacting the facility multiple times without response from management.

Three (3) outside sources familiar with the facility were interviewed regarding the allegation. Two of the outside sources were unfamiliar with the response time from management. One outside source informed of circumstances where messages had been left with management multiple times with no return response.

Review of facility records showed written requests made by a resident's responsible party to be responded to by management. The records showed that three attempts were made to three persons in management by the responsible party over a twelve (12) day period with no return response from management.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Resident Services Director Nae Brownell, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20241209163025
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GARDENS AT ESCONDIDO
FACILITY NUMBER: 374604545
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2025
Section Cited
CCR
87468.2(a)(16)
1
2
3
4
5
6
7
87468.2(a)...residents shall have all of the following personal rights: (16) To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency.
1
2
3
4
5
6
7
Licensee certified that upon any future room substitutions, the resident/ responsible party will be provided the required written 30-day notice, per the facility's Residence and Care agreement and Title 22 regulations.
8
9
10
11
12
13
14
Based on records and interviews, Licensee did not provide written notice at least 30 days in advance to responsible parties regarding room changes. This posed a potential personal rights risk to 1 of 68 residents in care.
8
9
10
11
12
13
14
Licensee agreed to retrain staff on personal/additional personal rights with training sheets to be submitted by POC due date.
Type B
03/28/2025
Section Cited
CCR
87468.1(a)(9)
1
2
3
4
5
6
7
87468.1(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately.
1
2
3
4
5
6
7
Licensee agreed to audit the facility's process regarding resident and representative communication, and correct practices contributing to delays in response times.
8
9
10
11
12
13
14
Based on records and interviews, Licensee did not promptly respond to communications from a resident's representative. This posed a potential personal rights risk to 1 of 68 clients in care.
8
9
10
11
12
13
14
Licensee agreed to retrain staff on personal/additional personal rights with training sheets to be submitted by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/09/2024 and conducted by Evaluator Nacole Patterson
COMPLAINT CONTROL NUMBER: 08-AS-20241209163025

FACILITY NAME:GARDENS AT ESCONDIDOFACILITY NUMBER:
374604545
ADMINISTRATOR:MCBRIDE, FERLINAFACILITY TYPE:
740
ADDRESS:1342 NORTH ESCONDIDO BLVDTELEPHONE:
(760) 480-8155
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:101CENSUS: 68DATE:
03/07/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Resident Services Director Nae BrownellTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not ensure that resident had a working telephone.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Resident Services Director Nae Brownell.

On 12/09/2024 it was alleged that Licensee did not ensure that resident had a working telephone upon a room change. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, outside sources, and records review. Staff interviews revealed that a communal telephone was available to residents in the common area at all times. Staff informed that residents and/or responsible parties were responsible for ensuring provision and maintenance of private telephones in a resident's apartment, if desired. These statements were verified by the facility's Residence and Care Agreement as well as an outside source who confirmed knowledge that families were responsible for contracting the phone company for a private phone in resident rooms.
(Continued on LIC9099-C p.2)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
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-20241209163025
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GARDENS AT ESCONDIDO
FACILITY NUMBER: 374604545
VISIT DATE: 03/07/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continued from LIC9099 p.1)

Evidence exists that the Licensee did not provide written notice within the required timeframe of a resident's permanent room substitution in order for the responsible party to set up the phone. However, due to the facility having a communal telephone for use, the telephone access requirement was met. During an unannounced facility visit on 02/21/2025 LPA directly observed the communal phone provided by the facility and confirmed that it was in working order.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Resident Services Director Nae Brownell, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5