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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804161
Report Date: 12/10/2024
Date Signed: 12/10/2024 10:45:59 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
10/10/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241010100627
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: 42DATE:
12/10/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Veronica De-Leon (Assisted Living Director)TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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-Resident sustained unexplained injury while in care.
-Residents do not have reasonable access to the facility telephone to receive confidential calls.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Cuadra and Stevenson arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Veronica De Leon, Assisted Living Director.

The Department received an allegation of resident sustained unexplained injury while in care. Per reporting party, on 10/1/24 staff from the facility reported to resident’s (R1) responsible party that R1 had a bruise over their eye. On 10/2/2024 after inquiring about R1’s black eye and eye was swollen, the facility supposedly investigated, but none of the staff could explain what happened. On 10/10/2024, LPA conducted complaint visit, LPA reviewed records, conducted interviews, and made observations at the facility. Based on records review, the facility provided LPA with charting narrative entered as follow: On 10/1/24 at approximate 1:30pm, R1 was seen with discoloration of their left eye and above, no pain was noted, and R1’s physician was notified for guidance and next day there was an appointment for x-rays to be done.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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 5
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
10/10/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241010100627

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: 42DATE:
12/10/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Veronica De-Leon (Assisted Living Director)TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
--Staff did not notify resident's authorized representative of resident's change of condition.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Cuadra and Stevenson arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Veronica De Leon, Assisted Living Director.

Regarding allegation of staff did not notify resident's authorized representative of resident's change of condition. Reporting party alleges that R1 had a change in condition and the facility did not notify their responsible party. When R1 was admitted to the facility they could use the restroom on their own, but recently facility started putting depends on them and their responsible party is unaware of when the change occurred. Based on records review, R1’s physician report dated 3/1/24 indicates that R1 is ambulatory and has the capacity of perform activities of daily living (ADL’s). Also, R1’s appraisal dated 5/1/24 confirmed that there were no services needed. Facility records of communication with R1’s physician dated 9/10/24 revealed that the facility reached out to R1’s physician requesting an evaluation for home health due to R1 has been having frequent episodes of leaning forward during ambulation, and unstable gait. Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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 5
Control Number 21-AS-20241010100627
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
VISIT DATE: 12/10/2024
NARRATIVE
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Continued from LIC9099A...

Also, R1 is not able to eat on their own, decreased their engagement with other residents for activities and willingness to perform ADLs. On 10/10/24 during LPA’s annual visit, the facility printed R1’s care plan, which did not indicate any change of condition. However, the facility provided LPA with ADL’s log for the months of September 2024 and October 2024 revealing that R1 have been assisted with ADLs, but they were not able to provide evidence that R1’s responsible parties were notified about R1’s change of condition. 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 cited on the attached LIC 9099D. Appeal Rights Given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20241010100627
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: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2024
Section Cited
CCR
87463
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87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff…when there is significant change in the resident’s condition…This requirement has not been met as evidence by:
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Facility to submit a plan of how facility will ensure future compliance regarding notifying resident's responsible parties after a change of condition is noticed by POC due date to clear the deficiency.

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Based on records review, the facility did not notify resident’s (R1) responsible party about R1’s change of condition, which possess potential health, safety, personal rights risk to clients 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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20241010100627
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
VISIT DATE: 12/10/2024
NARRATIVE
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Continued from LIC9099...

On 10/7/24, R1’s physician recommended to have MRI of the spine and the facility notified R1’s responsible party. On 10/20/24 R1 was admitted to home health and responsible parties were notified. After reviewing incident reports log from the facility, LPA was unable to find any reports made to the Department about this incident and no further details were documented regarding any investigation been conducted by the facility. LPA will address reporting requirements in a case management. According to R1’s physician report dated 3/1/24, R1 has a diagnosis of dementia and did not have a history of skin condition prior to this incident. Based on confidential interviews conducted by LPA with staff, residents, and outside parties, R1’s cause of injury is undetermined, the investigation revealed the facility seek timely medical attention and responsible parties were notified. A finding that the complaint allegation occurs of resident sustained unexplained injury while in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Another allegation about residents do not have reasonable access to the facility telephone to receive confidential calls. According to the reporting party, the main phone number to the facility has been out of service for a month. The only way to get a hold of residents is by contacting the facility Director on their work phone, which doesn’t ensure the confidentiality of the calls. Based on records review, the facility provided LPA with an email dated 8/29/24 at 9:18am showing a mass email sent to various resident’s responsible parties including R1’s responsible party. During interviews conducted by LPA with outside parties it was confirmed that the facility has sent them written notifications via e-mail about new facility number. A finding that the complaint allegation occurs of resident do not have reasonable access to the facility telephone to receive confidential calls is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5