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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804161
Report Date: 02/28/2024
Date Signed: 02/28/2024 10:56:18 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240109113344
FACILITY NAME:VISTA PRADOFACILITY NUMBER:
486804161
ADMINISTRATOR:CHO, LINDAFACILITY TYPE:
740
ADDRESS:105 POWER DRIVETELEPHONE:
(707) 643-7617
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:68CENSUS: 34DATE:
02/28/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Veronica de Leon-TanTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility is not properly cleaning a resident in care.
Facility is not giving resident water.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Leibert arrives unannounced for the purpose of delivering findings on this complaint. Complainant alleges that facility has not been bathing the Resident (R1) and has not given R1 water which has resulted in R1 contracting an UTI. This investigation has included a review of documents, taking statements from witnesses and making site visits to the facility. The following determinations are made: Staff state that R1 is encouraged to drink water at regular intervals; LPA has observed water stations through out the facility set up for the residents; Staff state they have followed R1's care plan regarding hygiene; Care logs (ADL) indicate R1's care plan has been followed and that R1 has refused hygiene activities on 10 occasions in December 2023 and January 2024. Although the allegations may be true, based on statements and documents, there is not a preponderance of evidence to prove or, disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED.

Report left.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240109113344

FACILITY NAME:VISTA PRADOFACILITY NUMBER:
486804161
ADMINISTRATOR:CHO, LINDAFACILITY TYPE:
740
ADDRESS:105 POWER DRIVETELEPHONE:
(707) 643-7617
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:68CENSUS: 34DATE:
02/28/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Veronica de Leon-TanTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not prevent resident from eloping from the facility.
Staff not allowing resident to consume food of their choice.

INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Leibert arrives unannounced for the purpose of delivering findings on this complaint. Complainant alleges Staff did not prevent R1 from eloping from the facility and that visitors have been told not to bring food to the facility for R1. This investigation has included a review of documents, taking statements from witnesses and making site visits to the facility. The following determinations are made: Unusual Incident/Injury Report dated 4/15/2022 which was submitted to CCL by the facility documents that R1 eloped from the facility on April 11, 2022 and was returned safely an hour later; Administration denies telling visitors not to bring food to facility for R1; Two witnesses state that they have been told by Administration not to bring food for R1 to the facility. Based upon the statements made and documents reviewed, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
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 3
Control Number 21-AS-20240109113344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VISTA PRADO
FACILITY NUMBER: 486804161
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2024
Section Cited
CCR
87705(b)(2)
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87705(b)(2) Care of Persons with Dementia. … Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. ***Based upon review of documents, this requirement not met as evidenced by: On 4/11/2022, R1
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 Cleared at time of visit. This issue was addressed on 7/14/2022 on a case management basis when it was determined that facility had modified fencing in response to the elopement.

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wandered off facility property alone until returned an hour later. This posed an immediate risk to safety of R1.
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Deficiency Dismissed
Type A
03/01/2024
Section Cited
HSC
1569.269(a)(16)
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1569.269(a)(16) Enumerated Rights. To reasonable accommodation of individual needs and preferences in all aspects of life in the facility, except when the health or safety of the individual or other residents would be endangered.*** Based on statements, this requirement

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Administration will review 1569.269 and will submit a declaration of completion to CCL by POC date in order to clear the deficiency.
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 not met as evidenced by: R1’s visitors were told by staff not to bring outside food to R1 at the facility. This posed an immediate violation of R1’s enumerated rights.

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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.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3