Vista Del Lago Memory Care

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident sustained multiple fractures due to staff neglect.

Licensing Program Analyst (LPA) Javina George conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, the LPA met with Marie Hill, Executive Director and explained the reason for the visit. On 11/21/2023, the Riverside Adult and Senior Regional Office (RO) received a complaint regarding Neglect/Lack of Care and Supervision to Resident #1 (R1) resulting in chronic fractures in right wrist and right shoulder. According to information obtained during the Department’s investigation, R1 was admitted to the Vista Del Lago Memory Care facility on 01/22/2022. R1 needed little to no assistance with their activities of daily living (ADLs), however, R1 needed standby assistance when dressing, grooming and toileting. According to R1’s physician’s report, dated 01/19/2022, R1 was documented as ambulatory but could not independently transfer to and from bed. Although R1’s physician report, dated 10/02/2023, changed to indicate R1 was non-ambulthe state’s words, verbatim · CDSS document, Aug 22, 2025 · control 18-AS-20231121112448

Allegation investigated: Staff prevented the resident from enrolling in the Assisted Living Waiver (ALW) Program

On 7/29/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit at the facility to investigate the allegation listed above. LPA met with Administrator, Marie Hill who was informed of the purpose of the visit. LPA toured the facility, conducted interviews, and obtained copies of pertinent records. Regarding the allegation, “Staff prevented the resident from enrolling in the Assisted Living Waiver (ALW) Program” it was alleged Resident 1 (R1) required a lower level of care and facility staff denied R1 a more suitable housing option by failing to follow up on the Assisted Living Waiver (ALW) program status in a timely manner. During the visit, R1 was unavailable for an interview. LPA reviewed R1’s admission agreement dated 1/19/2023. LPA reviewed R1’s physician’s report dated 7/1/2025 noting R1 exhibits memory loss. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 29, 2025 · control 18-AS-20250723140804

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Neglect

On 12/11/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to deliver investigative findings regarding the allegation listed above. LPA met with Administrator, Marie Hill who was informed of the purpose of the visit. It was alleged Resident 1 (R1) sustained a cut on Sunday, 11/17/2024 and the facility did not seek appropriate medical attention. LPA reviewed R1’s Physician’s Report (LIC 602A) dated 1/5/2024 noting R1 exhibits confusion, wandering behavior, and is unable to communicate their needs or follow instructions. Facility staff on duty at the time of the discovery of the wound contacted Resident Services Director (RSD), Priscilla Bermudes for further instruction based on the severity of the wound. RSD was interviewed and reported on 11/17/2024, they received a phone call from facility staff reporting R1 was observed with an open area to their lower left leg. RSD added they also received a photograph of the wound and directed facility staff to not activatethe state’s words, verbatim · CDSS document, Dec 11, 2024 · control 18-AS-20241125114737

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff failed to ensure resident's insulin orders were followed

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to initiate the investigation into the allegations listed above. LPA met with Executive Director Marie Hill and explained the purpose of the visit. Complaint investigation consisted of a tour of the interior/exterior areas of the facility, interviews with staff and residents, and records review of requested pertinent documents. Regarding the allegation “Staff failed to ensure resident's insulin orders were followed” it was reported Resident One (R1) is not receiving insulin five times a day as prescribed by R1’s physician. Records review of R1’s Physician’s Orders reveal R1 is prescribed two separate insulin dosages in the morning, one insulin dosage in the afternoon, and two separate insulin dosages in the evening. Record review of R1’s Medication Administrator Record (MAR) for June 2024, July 2024, and August 2024 provides corroborating documentation of R1 receiving five shots of insulin prescribed by Rthe state’s words, verbatim · CDSS document, Sep 4, 2024 · control 18-AS-20240829163133

Allegation investigated: Staff are not ensuring that insulin is being administered in a safe manner.

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegations listed above. LPA met with Executive Director Marie Hill and explained the purpose of the visit. Complaint investigation consisted of a tour of the interior/exterior areas of the facility, interviews with staff and residents, and records review of requested pertinent documents. Regarding the allegation “Staff are not ensuring that insulin is being administered in a safe manner” it was reported Resident One (R1) receives insulin twice a day and staff are not checking R1’s blood sugar. Interview with Staff One (S1) reported R1 has a physician’s order stating R1’s blood glucose checks will be conducted one time a day on every Monday with a start date of 06/03/2024. LPA conducted a records review of R1’s order summary report that corroborates R1’s physician’s orders for blood glucose checks on Monday only. Records review of Medication Administrator Record (MAthe state’s words, verbatim · CDSS document, Aug 26, 2024 · control 18-AS-20240619165645

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Licensee not meeting the resident's care needs

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Executive Director, Marie Hill. During the investigation, records were reviewed, and interviews conducted with staff and outside sources. It was alleged the licensee was not meeting the needs of Resident #1 (R1). It was reported R1 was not kept clean, urinated on themselves, and was left in soaking wet clothing for an extended period, and was in pain from an untreated Stage II pressure injury. R1’s Physician’s Report dated 09/25/20 indicated R1 was incontinent of bladder, required assistance with bathing, dressing/grooming, and medication management. R1’s Service Plan dated 10/14/20 indicated R1 required assistance with showers on Tuesdays and Fridays, occasional assistance with transfers, and medication management. The Service Plan also reflected R1 was continent of bladder but required assistance with bowel incothe state’s words, verbatim · CDSS document, Apr 18, 2024 · control 08-AS-20201106075652

Allegation investigated: Staff’s lack of supervision resulted in resident sustaining multiple falls and hospitalization Staff left resident soiled on the floor

Licensing Program Analyst (LPA) Sara Martinez made an unannounced visit to the facility to deliver findings for the allegation noted above. LPA was granted entry and met with Executive Director Marie Hill and discussed the details pertaining to the complaint. Regarding the allegation “Staff’s lack of supervision resulted in resident sustaining multiple falls and hospitalization” it was reported Resident One (R1) had fallen multiple times resulting in hospitalization. Record review revealed R1 had four (4) unwitnessed falls on (01/04/2024, 12/14/2023, 12/01/2023, 11/28/2023) and one (1) witnessed fall on 01/03/2024. Falls from 01/04/2024 and 12/14/2023 required R1 to be taken to the hospital. A record review revealed that at the time of all 4 unwitnessed falls there was sufficient staffing with two (2) Med Tech and seven (7) Caregivers during both the AM and PM shifts and four (4) caregivers for overnight. The facility had a total of 89 residents during the time of the incidences noted.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 18-AS-20240129091639

Allegation investigated: Resident was sexually assaulted while in care

Licensing Program Analyst (LPA) Sara Martinez made an unannounced visit to the facility to deliver findings for the allegation noted above. LPA was granted entry and met with Executive Director Marie Hill and discussed the details pertaining to the complaint. Regarding the allegation “Resident was sexually assaulted while in care”, it was reported an unknown individual entered Resident One’s (R1) room and attempted to abuse and hurt R1. Interview with LVN Alicia Anderson revealed the unknown individual is a resident, Resident Two (R2). On 02/23/2024, R1 was calling for help to assist R1’s roommate when R2 entered their room without R1’s consent and sat on R1’s bed. R1 yelled at R2 to get out of their room and R2 did not leave the room. R2 stated they wanted a kiss and R2 gestured with their hands to perform a sexual act. R1 began to push R2 out of their room with R1’s walker. Staff One (S1) arrived at R1’s room to assist with re-directing R2 back to their own room. S1 noted no injuriesthe state’s words, verbatim · CDSS document, Mar 21, 2024 · control 18-AS-20240226114855

Allegation investigated: Facility staff dropped resident during transfer. Facility did not notify responsible party of staff dropping resident.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings for the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Marie Hill. On November 24, 2020, Community Care Licensing (CCL) received a complaint alleging Resident 1 (R1) was dropped by facility staff and such fall was not reported to the responsible party. During the investigation, the Department collected pertinent resident records as well as facility documentation and conducted interviews. According to R1’s Physician Report, dated September 25, 2020, R1 has a mild cognitive impairment, is non-ambulatory, and requires minimal assistance with activities of daily living. R1’s Plan of Care dated October 10, 2020, states R1 requires assistance with transfers with verbal cueing. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 13, 2024 · control 08-AS-20201124123344

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.