Vista Del Lago Memory Care

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff neglect resulted in resident severe dehydration Staff are not ensuring resident is being repositioned, resident developed pressure injury while in care Staff did not assist resident with meal service Staff did not safeguard residents personal belongings from going missing

On 9/17/2026 at 9:00am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to conduct a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Marie Hill and explained the purpose of the visit. On 10/20/2022, the Riverside Adult and Senior Care Regional Office (RO) originally received this complaint regarding neglect/lack of care and supervision. The complaint alleged that Resident #1 (R1) was severely dehydrated and developed stage two pressure injuries while in care at the facility due to staff neglect and lack of care and supervision. The complaint also included allegations that staff did not assist residents with meal service and staff did not safeguard resident’s personal belongings from going missing. (Continued on LIC9099-C) Unsubstantiated On 10/21/2022, from 10:03am to 1:15pm, LPA Arreola conducted an unannounced initial complaint investigation visit to the facility. LPA Arreola met with Executive Director/Administrator at the time, Levina Dubose and explained the reason for the visit. During the visit, the LPA collected documentation for R1 including admissions agreement, physician report, last doctor's visit and lab work, progress notes, the resident's medication administration record (MAR), centrally stored list of medications, and latest care plan. LPA also interviewed the Executive Director. Additionally, the Department conducted interviews; on 10/31/2022, from approximately 9:00am to 11:20am, with the Administrator Levina Dubose and other staff; on 10/31/2022 at approximately 11:20am, with a witness; and on 4/7/2023 at approximately 11:20am, with Person #1 (P1). In addition, the Department reviewed records from Elizabeth Hospice, Temecula Hospital, the County of Riverside, and facility documents related to the investigation. On the allegations, staff neglect resulted in resident severe dehydration, staff are not ensuring resident is being repositioned, resident developed pressure injury while in care, and staff did not assist resident with meal service; It was alleged that the facility was serving R1 mechanical soft foods, but staff were not assisting R1 eat their food and when visitors visited R1, R1 was asleep with food still in their mouth. It was also alleged that the neglect of the facility staff led to R1’s rapid decline that led to R1’s transfer to the hospital on 10/1/2022 where R1 was diagnosed with severe dehydration, an electrolyte imbalance, and a stage two pressure injury on their coccyx. R1 passed away in the hospital on 10/9/2022 due to cardiopulmonary arrest. Review of R1’s physician’s report (LIC602A) dated 8/30/2022 reveals R1’s primary diagnosis as Alzheimer’s disease and secondary diagnosis of palliative care. It also states R1 had dysphagia, requiring a mechanical soft altered texture diet and thin liquids. Hospice records also state R1 was diagnosed with vascular dementia with behavioral disturbance, chronic kidney disease stage 3, anxiety disorder, gastro-esophageal reflux disease, and hypersomnia. Among the medications R1 was prescribed were Seroquel 25mg one tablet every morning, Seroquel 200mg one tablet every night, Zoloft 25mg one tablet daily, and Depakote 250mg one capsule twice daily. (Continued on LIC9099-C) The Department’s review of R1’s hospice records indicate R1 was transferred from one hospice agency to The Elizabeth Hospice agency on 6/20/2022. Subsequently, R1 was admitted to a skilled nursing facility (SNF). The Elizabeth Hospice agency continued to care for R1 during their stay at the SNF and after they moved into this facility on 8/31/2022. Hospice notes from a visit with R1 at the SNF on 8/30/2022 state R1 needs to be fed, has increased daytime sleep, requires assistance dressing, bathing, grooming, and with incontinence. It also states R1’s skin was intact with no abnormalities noted and that R1’s appetite was fair. Records indicate that a hospice nurse from the agency visited R1 at this facility on 8/31/2022 (the day they were admitted), 9/6/2022, 9/8/2022, 9/15/2022, 9/22/2022, 9/27/2022, and 9/30/2022. On 9/2/2022 hospice ordered clotrimazole cream 1% with z-guard to apply twice daily to affected areas on buttocks and a note from a nurse visit on 9/3/2022 states the cream was ordered due to evidence of skin breakdown, that appeared beefy red to buttocks bilaterally. A hospice aide provided bathing assistance to R1 at the facility on 9/1/2022, 9/8/2022, 9/15/2022, 9/21/2022, 9/28/2022, and 9/30/2022. During the visits on 9/15/2022 and 9/21/2022 the hospice aide noted red areas on R1’s bottom that staff and the hospice nurse were aware of. The facility medication administration records indicate the cream was administered twice daily by staff. Multiple staff interviews revealed that care staff were repositioning R1 frequently throughout the day and using the cream as prescribed. Staff also stated they would get R1 up in a wheelchair, but they would yell out and scream in public spaces and when R1 was in their room in bed they seemed more comfortable. During a virtual care conference conducted on 9/26/2022 held by hospice staff with facility staff and R1’s family, R1’s care was reviewed, including their inconsistent sleep pattern, decline in food and fluid intake, medications and R1’s wishes for limited treatment and no artificial nutrition. At the care conference the concern of a sore developing in R1’s mouth was also discussed and a hospice physician order stating R1 may have puree diet was provided to the facility. (Continued on LIC9099-C) On 9/27/2022 a hospice nurse conducted an oral check noting R1 to have a skin growth on the roof of their mouth, pinkish in color with no drainage. Staff reported that R1 had 75% of their breakfast that morning and staff stated it did not appear the growth impeded R1’s swallowing. Staff interviews reveal that when R1 moved into the facility they ate and drank with staff assistance, but during the week prior to R1 going to the hospital on 10/1/2026 they appeared to be declining. Hospice records document that on 9/30/2022 staff notified hospice that R1 had not been eating for the last couple of days, spitting their food out, pocketing it in their cheek, and not opening their mouth for more. Staff interviewed reported that R1 would not swallow their food and would keep the food in the pocket of her mouth or spit it out, staff reported they attempted various methods to get R1 to swallow, eat and drink. Interviews also reveal staff were instructed by hospice not to force R1 to eat or drink. Interviews and record review indicate that on 10/1/2022 R1’s family requested they be sent out 911 due to a continued decline and R1 was transported to Temecula Valley Hospital where they were diagnosed with dehydration. Hospital notes also state R1 had a soft tissue mass in the roof of their mouth, but no open wounds or evidence of intraoral infection. Additionally, a note indicates R1 had an unstageable pressure injury on the midline of their sacrum that was present on admission. A death certificate from the County of Riverside indicates R1 passed at the hospital on 10/9/2022 with an immediate cause of death as cardiopulmonary arrest. Based on all interviews conducted and documents received, at this time the above allegations were found to be unsubstantiated, meaning that the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. On the allegation, staff did not safeguard residents personal belongings from going missing; it was alleged that half of R1’s personal belongings went missing, specifically clothing and shoes. It is alleged that other residents were observed walking around wearing R1’s clothing and that residents would walk into R1’s room and take their belongings. This was allegedly reported to the facility Administrator at the time, Levine Dubose, and the facility did not offer to replace the missing items. (Continued on LIC9099-C) Review of R1’s Admission Agreement states “we will make a reasonable effort to assist residents in maintaining possession and protection of personal items. However, personal items, including but not limited to items of clothing, prescription glasses, dentures or hearing aids, may be lost or misplaced. We shall not be responsible for loss of any personal property, unless such loss or damage was caused by the negligence or intentional misconduct of our employees.” Records reveal that no personal property inventory record for R1’s personal items was completed. Based on all interviews conducted and documents received, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, report signed, and report provided to the current Administrator.the state’s words, verbatim · CDSS document, Sep 17, 2026 · control 18-AS-20221020110131

Allegation investigated: Facility staff did not notify resident's representative of a medical procedure conducted on the resident.

On April 26, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial, unannounced complaint visit. Brianna Garcia Licensed Vocational Nurse, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, inspection of the faciltiy and a collection of records. The Department reviewed several documents, including the Facility Staff Roster (dated 04/25/26 & 06/16/25), Facility Resident Roster (dated 04/25/26 & 06/16/25), Miso Dermatology Authorization and Consent Form (date 07/16/24), Consent for Emergency Medical Treatment, LIC 627 (dated 06/04/24), Physicians Report LIC 602A (dated 05/06/24), Preplacement Appraisal Information LIC 603 (dated 05/30/24), Move In Record (dated 06/13/24), Physicians Order for Life Sustaining Treatment (dated 05/06/24), Declaration of Health Agent (dated 06/04/24), Comfort and Peace Records (dated 01/16/25), and other pertinent records associated with this complaint. Interviews conducted with Staff #1-#5, Resident #2-#9, and Witness #1-#3. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Facility staff did not notify resident's representative of a medical procedure conducted on the resident. The complaint alleges that the staff at the facility did not inform Resident #1’s (R1) representative about a medical procedure that took place. Specifically, it states that on February 4, 2025, a biopsy was performed on (R1), which required two stitches on (R1’s) lower left back, as reported by the hospice nurse. Additionally, it is claimed that the facility administrator was unaware of this procedure. No further information regarding the allegation has been provided. On April 25, 2026, between 9:45 AM and 11:59 AM, the Department interviewed resident members identified as Resident #2 through Resident #9 (R2-R9). Eight (8) out of the (8) were unable to support this claim. (R2-R9) appreciated the staff and reported no issues with notifying their representative about medical treatments, procedures, or hospitalization. (R2) shared that staff member #1 (S1) showed kindness by visiting (R2) during a hospital treatment. (S1) offered support and brought personal items during this difficult time. Resident #1 (R1) was not available for an interview as the resident had passed on April 8, 2025. On April 25, 2026, between 8:40 AM and 3:35 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members could not corroborate this allegation. Staff members (S1-S5) reported that they are responsible for notifying resident representatives about medical events or procedures. (S1, S2, and S5) stated that a resident's authorized representatives are informed whenever a medical procedure is performed or the resident's condition changes. Specific forms, logs, and communication tools are used for this purpose, including phone calls, voicemails, emails, and written notifications. Additionally, (S1 and S5) indicated that in the case of (R1), the biopsy treatment was performed by Mismo Dermatology, an in-house service provider, who worked with (R1's) authorized representatives to obtain authorization and consent for the treatment. On February 9, 2026, and April 25, 2026, between 03:30 PM and 04:30 PM, the Department attempted to interview witness members identified as Witness #1 through Witness #3. (W1) was interviewed but decided not to proceed, stating that they are no longer affiliated with Vista Del Lago Memory Care. (Evaluation Report continues LIC 9099-C) (W1) thinks that their past connection might not reflect the current situation and could have caused some issues. (W2-W3) were unavailable for interviews as calls went unanswered. The Department reviewed Resident #1 (R1's) service file which included the Miso Dermatology Authorization and Consent Form (date 07/16/24) it indicated "I hereby authorize and consent to any of the following operation(s) or procedure(s) as deemed medically necessary by the provider": biopsy, liquid nitrogen freezing, local anesthetics, phototherapy, complex wound excision, and other skin procedures. Representative authorization appears in the patient's signature dated 07/16/24. A review of the Consent for Emergency Medical Treatment, LIC 627 (dated 06/04/24) indicated that an authorized representative signed the form. Further review of (R1’s) Physicians Report LIC 602A (dated 05/06/24), Preplacement Appraisal Information LIC 603 (dated 05/30/24), Move In Record (dated 06/13/24), Physicians Order for Life Sustaining Treatment (dated 05/06/24), Declaration of Health Agent (dated 06/04/24), Comfort and Peace Records (dated 01/16/25), Facility Progress Notes (dated 02/5/25 & 02/07/25), Medication Administration Record (dated 02/01/25 through 02/28/25), Miso Dermatology Notes (dated 02/04/25) and Residence and Care Agreement (dated 06/04/24). Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted with Brianna Garcia, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Apr 26, 2026 · control 18-AS-20250206113759

Allegation investigated: Lack of staff supervision resulting in residents engaging in a physical altercation.

On April 26, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial, unannounced complaint visit. Brianna Garcia Licensed Vocational Nurse, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, inspection of the faciltiy and a collection of records. The Department reviewed several documents, including the Facility Staff Roster (dated 04/25/26 & 06/16/25), Facility Resident Roster (dated 04/25/26 & 06/16/25), Physicians Report LIC 602A (dated 09/23/23) Service Plan Report (dated 06/16/25), Medication Administration Record (dated 02/01/25 through 02/28/25), Residence and Care Agreement (dated 06/04/24), Move In Record (dated 06/16/25), Palomar Medical Records (dated 06/09/25) and Unusual Incident/Injury Report LIC 624 (dated 06/11/25), and other pertinent records associated with this complaint. Interviews conducted with Staff #1-#5, Resident #2-#9, and Witness #1. (Evaluation Report continues on LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Lack of staff supervision resulting in residents engaging in a physical altercation. The complaint alleges that a lack of supervision led to a physical altercation among residents. It has been reported that Resident #1 (R1) and Resident #2 (R2) were involved in an incident that resulted in (R1) being admitted to the hospital with a closed ankle fracture. Further reports indicate that the altercation occurred in (R1's) room after (R2) entered, resulting in a confrontation. No additional information regarding the allegation has been provided. On April 25, 2026, between 9:45 AM and 11:59 AM, the Department interviewed resident members identified as Resident #2 through Resident #9 (R2-R9). Eight (8) out of the (8) were unable to support this claim. (R2-R9) were all complimentary of the staff and expressed that they received adequate care, support and supervision in a responsive manner. (R2) could not recall the incident that occurred on June 08, 2025, with (R1) and denies having any physical altercations. (R2) stated to be on a friendly relationship with (R1). Resident #1 (R1) was not available for an interview as the resident is currently being treated at Santa Fe Post Acute and did not return calls. On April 25, 2026, between 8:40 AM and 3:35 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members could not validate this allegation. Staff members (S1-S5) expressed care and supervision are priority for all staff. According to (S1-S5), there have been no prior verbal or physical altercations between Residents #1 (R1) and #2 (R2). Both residents are diagnosed with Major Neurocognitive Disorder (NCD) and exhibit behaviors associated with this condition. However, neither requires one-on-one care. (S5), who was present during the incident, reported that two other staff members, along with (R1) and (R2), immediately responded when they heard yelling and noises coming from (R1's) room. (S5) explained that (R2) wandered into (R1's) room, mistakenly thinking it was (R2’s) own room, and sought to use the bathroom. During this encounter, a verbal and physical altercation occurred, wherein (R1) grabbed (R2) by the arm, prompting (R2) to push (R1), who then fell to the floor. Following the incident, (R1) complained of leg pain and was taken to the hospital. (S1-S2) disputed claims of a lack of supervision, emphasizing that the facility has adequate staffing, trained personnel, immediate communication via walkie-talkies, and surveillance cameras in place. (S1) detailed the staffing for different shifts: the morning (AM) shift consists of five caregivers, two med-techs, and one nurse; the afternoon (PM) shift includes five caregivers, two med-techs, and one nurse; while the evening (NOC) shift has four caregivers and one med-tech. (Evaluation Report continues LIC 9099-C) (S1-S2) outlined their plan for handling staffing shortages, call-outs, and schedule changes affecting supervision. Staff must secure their own coverage when they call out, and any staffing emergencies are managed through agencies like Clipboard Health. Furthermore, all staff members (S1-S5) have confirmed completion of the required 40 hours of in-service and hands-on shadow training related to (NCD). On April 25, 2026, between 9:30 AM and 04:30 PM, the Department attempted to interview witness members identified as Witness #1 (W1). (W1) was unavailable for an interview as calls went unanswered. The Department reviewed Resident #1 (R1’s) service file which included Physicians Report LIC 602A (dated 09/23/23) Service Plan Report (dated 06/16/25), Medication Administration Record (dated 02/01/25 through 02/28/25), Residence and Care Agreement (dated 06/04/24), Move In Record (dated 06/16/25), Palomar Medical Records (dated 06/09/25) and Unusual Incident/Injury Report LIC 624 (dated 06/11/25 and it revealed that (R1) is medically evaluated with occasional agitation behavior. Further review of Resident #2 (R2’s) service file included Physicians Report LIC 602A (dated 06/03/25) Resident Appraisal LIC 603A (dated 06/06/24), Residence and Care Agreement (dated 06/17/24), Move In Record (dated 06/16/24), Unusual Incident/Injury Report LIC 624 (dated 06/11/25 and it revealed that (R2) is medically evaluated with wandering behavior and no aggressive behavior. Additional analysis of personnel Care Staff Assignments (dated 06/08/25), Personnel Report LIC 500 (dated 04/25/26) and Relias In-Service Training (dated 01/15/26, 02/19/26, 02/20/26 and 04/24/26) revealed confirmation of number of personnel for each work shift and completed mandatory training requirements. During the visit on April 25 and 26, 2026, the Department identified that the facility promotes the rights and safety of its residents. Posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted with Brianna Garcia , and copies of the reports were provided.the state’s words, verbatim · CDSS document, Apr 26, 2026 · control 18-AS-20250609165814

Type of visit: Case Management - Incident

On 04/08/2026, Licensing Program Analyst (LPA) Aziz Faizi conducted an unannounced case management visit to the facility to follow up on an Unusual Incident/Injury Report (LIC 624) submitted by the facility reporting an incident involving Resident 1 (R1). LPA met with Executive Director, Marie Hill who was informed of the purpose of the visit. The LIC 624 reported the following information. On 04/03/2026, At approximately 6:20 pm staff received a call that R1 was found outside at the church located near the facility. Staff immediately went outside to check and upon arrival resident was observed outside of the facility. Staff redirected R1 back inside the facility after multiple attempts. Executive Director was interviewed and reported the following information. The doors of the facility are kept closed and were checked in the morning and in the afternoon before residents were allowed to be in the East wing of the facility and found to be secured. There were concerns of the residents according to the Executive Director. During LPA’s observations LPA found that there were doors and gates that lead to the outside were secured and gates have an alarm that can be heard inside the facility, however according to S1 they stated that they did not hear any alarm go off the day of the incident. During the visit LPA was shown video footage by Executive Director that disclosed that R1 had pulled the door open and left the facility. Staff were not aware of R1 leaving the facility. Additional maintenance and witnesses were interviewed but did not disclose any additional information. During today's visit, LPA toured the facility did not observe any immediate health and safety concerns. Based on interviews and video footage a citation including with proof of correction has been issued. Additionally an alarm system will be installed by 04/24/2026 at the east side exit door. An exit interview was conducted, and a copy of this report, LIC 809-D, were reviewed and provided to Administrator, Marie Hillthe state’s words, verbatim · CDSS document, Apr 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f) · Plan of correction due date: Apr 10, 2026

Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements... Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residentsthe state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: Executive Director shall install an alarm system at exit door if door is open and locked unlawfully without proper keys. Additinally a completion of proper employee retraining regarding the handling and observation of dementia care clients in care is required by the POC due date.

Allegation investigated: Staff did not provide the medication as prescribed. Staff is not providing proper hygiene assistance to resident and not providing clean fresh clothing. Staff is not responding to the needs of the residents.

On December 30, 2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit to deliver findings. LPA met with the Executive Director (A1), Marie Hill, and explained the purpose of the visit. The complaint investigations consisted of the following: On December 17, 2025, LPA Richard met with Loucinda Hickerson, Memory Care Director (MCD), and explained the purpose of the visit. Later, the Executive Director, Marie Hill (ED), joined. During the visit, LPA Richard requested and received copies of the following: Staff Roster (dated 12/17/25), Resident Roster (dated 12/15/25), R1 Face Sheet, Admission Agreement (dated 07/08/24), Physician’s Report (dated 06/06/24), Needs and Services Plan (dated 3/26/24), R1’s Medication Administration Record (MAR) (dated 09/01/24 to 09/30/24), Facility Notes (dated 07/01/24 to 11/30/24), Med Technician Training Certificate (dated 03/09/23). LPA Richard also conducted interviews with the Executive Director (A1), Memory Care Director (MDC), six residents (R2-R7), four staff members (S1-S4), and two Med Techs (MT1-MT2). Unsubstantiated Allegations #1: Staff did not provide the medication as prescribed. The complaint alleged that the facility failed to administer medication as prescribed. On December 17, 2025, Licensing Program Analyst (LPA) Antonine Richard interviewed the Administrator (A1), who denied the allegation and stated that the Med Techs were being trained to administer medications to the residents. LPA also interviewed the Memory Care Director (MDC), who likewise denied the allegation. Additionally, LPA interviewed six residents #2-7 (R2-R7), all of whom denied the allegation and reported that staff provided their medications on time and without mistakes. LPA also interviewed four staff members (S1-S4), who denied the allegations and noted that they only assisted residents with their medications. During the same visit, LPA interviewed two Med Techs (MT1 and MT2), who denied the allegations and asserted that they followed the doctor's orders. They explained that if a prescription arrived from the pharmacy without the doctor's orders, they would contact the doctor and the pharmacy to have the necessary paperwork faxed before administering the medications. On December 17, 2025, LPA reviewed the medication administration records for five residents. MARs dated 09/01/2024 to 09/30/2024 showed no discrepancies. LPA was unable to interview R1 because R1 moved out of the facility on 11/06/2024. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegation is unsubstantiated. Report Continued on LIC9099C. Allegation #2: Staff are not providing proper hygiene assistance to residents and not providing clean, fresh clothing. The complaint alleged that a resident who has been at the facility for 2 months has had only two baths and wears the same clothes. On December 17, 2025, Licensing Program Analyst (LPA) Antonine Richard interviewed the Administrator (A1), who denied the allegation and stated that Resident #1 (R1) is very vocal. R1 would demand assistance from staff if R1 feels neglected. LPA also interviewed the Memory Care Director (MDC), who similarly denied the allegation. Additionally, LPA interviewed six residents (R2-R7), all of whom denied the allegation and reported that residents have scheduled showers and can refuse to be showered if they choose. LPA also interviewed four staff members (S1-S4), who denied the allegations and noted that R1 often refuses to take showers and change clothes. Since R1 has the right to refuse, the staff could not force R1. During the same visit, the LPA interviewed two Med Techs (MT1 and MT2), who denied the allegations and stated that staff tried to assist all residents needing help with showers and changing clothes. On December 17, 2025, the LPA reviewed the facility records from 07/01/2024 to 11/30/2024, which showed that R1 refused assistance from the caregiver multiple times with R1's Activities of Daily Living (ADLs). At the same time, the LPA also reviewed the facility's shower schedule for each resident. The LPA observed that most of the residents interviewed and those in the TV room were wearing clean clothes. LPA was unable to interview R1 because R1 moved out of the facility on 11/06/2024. Report Continued on LIC9099C Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegation is unsubstantiated. The allegation #3: Staff are not responding to the needs of the residents. The complaint alleged that a resident called for help, but no one responded. On December 17, 2025, Licensing Program Analyst (LPA) Antonine Richard interviewed the Administrator (A1), who denied the allegation and stated that Resident #1 (R1) is very vocal. R1 would request assistance from staff if needed. LPA also interviewed the Memory Care Director (MDC), who similarly denied the allegation. Additionally, LPA interviewed six residents #2-7 (R2-R7), all of whom denied the allegation and stated that the staff helped them when they needed them. The staff checked their rooms every half hour or one hour. LPA also interviewed four staff members #1-4 (S1-S4), who denied the allegations and noted that R1 rooms are closed to the Med Tech station and that staff would be able to hear if R1 asked for help. LPA was unable to interview R1 because R1 moved out of the facility on 11/06/2024. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to the Executive Director, MARIE HILL.the state’s words, verbatim · CDSS document, Dec 30, 2025 · control 18-AS-20240926160035

Allegation investigated: Staff did not seek timely medical treatment for resident. Staff do not intervene when a resident assaults another resident. Due to lack of supervision, resident had multiple falls.

On December 30, 2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint investigation and met with Loucinda Hickerson, Memory Care Director (MCD), and Executive Director Marie Hill. The purpose of the visit was explained. The Investigation consisted of the following: On December 17, 2025, the LPA Richard requested and received copies of the following: Staff Roster (dated 12/17/25), Resident Roster (dated 12/15/25), R1 Face Sheet, Admission Agreement (dated 03/13/24), Physician’s Report (dated 3/13/24), Needs and Services Plan (dated 3/26/24), R1’s Medication Administration Record (MAR) (dated 05/21/24 to 05/31/24), Facility Notes (dated 03/05/24 to 06/03/24), Med Technician Training Certificate (dated 03/09/23). LPA Richard conducted interviews with the Executive Director (A1), Memory Care Director (MDC), six residents (R2-R7), four staff members (S1-S4), and two Med Techs (MT1-MT2). Report Continue on LIC9099C Unsubstantiated Allegation #1: Staff did not seek medical treatment for the residents. The complaint alleged that staff contacted the responsible party after discovering residents in the facility's hallway who were shaking, unable to walk, and disoriented, instead of calling the Medical Emergency Service (MES). On December 17, 2025, LPA Richard interviewed the Administrator (A1), who denied the allegations. A1 stated that the facility has strict protocols in place. According to A1, there is no way the staff would fail to call EMS when necessary, and they likely informed the responsible party (RP) about the residents' conditions. Additionally, LPA Richard interviewed the Memory Care Director (MDC) on the same day, who also denied the allegations. MDC affirmed that the facility is trained to call EMS in urgent situations, followed by contacting the nurse. LPA Richard also interviewed four staff members, #1-4 (S1 to S4), all of whom denied the allegations and emphasized that resident care and well-being are their main priorities. After assessing the situation, the staff felt that resident R1 was stable and did not see the need to call EMS. Later that day, LPA Richard interviewed six residents #2-7 (R2 to R7). Five of the six residents denied the claim that the facility wouldn’t call EMS when needed, noting that the facility had called EMS for them on numerous occasions. Report Continued on LIC9099C LPA Records reviewed the facility notes dated June 3, 2024, which indicated that the Responsible Party (RP) visited R1 while R1 was eating. During the visit, the RP observed that R1 was alert and oriented but could not answer questions about R1's feelings. The RP decided it was best to take R1 to the emergency room for further evaluation, leading to R1's hospitalization that day. At the same time, LPA reviewed R1's Physician List of Medications. R1 was prescribed Levothyroxine (Aricept) 10 MG Tablet; the side effects of this medication include dizziness and disorientation. On June 5, 2024, the facility called the RP, who indicated that R1 might be discharged that day. However, the Executive Director mentioned that R1 never returned to the facility after the hospitalization. The LPA was unable to interview R1, as R1 no longer resides at the facility. LPA Richard was unable to interview R1 because R1 moved out of the facility on 6/01/2024. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (S) did or did not occur; therefore, the allegation is Unsubstantiated. Report Continued on LIC9099C Allegation #2: Staff do not intervene when a resident assaults another resident. The complaint alleged that some residents had confronted others, and the staff failed to intervene. On December 17, 2025, LPA Richard interviewed the Administrator (A1), who denied these allegations. A1 stated that the facility staff would intervene and redirect the residents as needed. According to A1, this is a memory care facility. Additionally, LPA Richard interviewed the Memory Care Director (MDC) on the same day, who also denied the allegations and affirmed that staff were trained to help redirect residents. LPA Richard conducted interviews with four staff members (S1-S4), all of whom denied the allegations. They emphasized that the facility's main priorities are resident care and well-being. The facility employs many staff members who are present on the floor with the residents. In the event of any altercation, these staff members are readily available to intervene, although such incidents are rare. Later that day, LPA Richard interviewed six residents (R2-R7). Five of the six residents denied the allegations and stated that the staff are always present to help redirect or assist the residents. During the visit, LPA Richard observed a significant number of staff on the floor engaging with the residents, participating in activities, watching TV, and conversing with one another. The LPA was unable to interview R1 because R1 moved out of the facility on 06/01/2024. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (S) did or did not occur; therefore, the allegation is Unsubstantiated. The allegation #3: Due to a lack of supervision, the residents had multiple falls. The complaint alleged that the residents had numerous falls due to the facility leaving the residents unsupervised. On December 17, 2025, LPA Richard interviewed the Administrator (A1), who denied these allegations. A1 stated that the facility staff had never reported that R1 had falls. The facility had a protocol for unwitnessed and witnessed falls. According to A1, the staff will call the Nurse, not move the resident, and make sure the resident is not in pain. Additionally, LPA Richard interviewed the Memory Care Director (MDC) on the same day, who also denied the allegations and affirmed that staff were trained on how to approach witness and unwitnessed falls. LPA Richard interviewed four staff members (S1-S4), all of whom denied the allegations. They emphasized that the facility's main priorities are resident care and well-being. They also stated they will call the nurse, ensure the resident is not in pain, and, if necessary, call EMS. Additionally, they mentioned that they checked residents' rooms every hour, with some being checked every half hour. Later that day, LPA Richard interviewed six residents (R2-R7). Five of these six residents denied the allegations and also stated that the facility checked their rooms every hour. On December 17, 2025, LPA records reviewed the facility notes dated April 17 and May 8, 2024, showed that during a room check, the staff member found R1 sitting on the floor of the R1 bedroom. The staff asked if R1 was in pain and said they would call 911, but R1 refused and wanted to go to Urgent Care. The facility then called RP, who stated that RP would come and take R1 to urgent care. During the visit, LPA Richard observed many staff members on the floor engaging with residents, participating in activities, watching TV, and talking with one another. The LPA was unable to interview R1 because R1 moved out of the facility on 06/01/2024. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (S) did or did not occur; therefore, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of the report was given to the Executive Director, Marie Hill.the state’s words, verbatim · CDSS document, Dec 30, 2025 · control 18-AS-20240606082459

Allegation investigated: Staff did not notify responsible party of a resident's fall resulting in medical attention. Staff failed to administer resident's medications as prescribed

On November 6, 2025, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Memory Care Director Loucinda Hickerson and the purpose of the visit was explained. Investigation consisted of the following: On 3/22/23 the Department conducted an unannounced initial visit to the facility to investigate the complaint allegations mentioned above. During the visit, it was determined that the complaint required further investigation. On November 5, 2025, the Department requested and received copies of the following: Staff roster (dated 10/4/25) Resident Roster (dated 10/22/25), R1's physician’s report (dated 9/8/22), R1's Needs and Services Plan (dated 2/19/23), R1 Physican's orders (dated August 2023), Staff Medication training (dated 11/29/23). The Department conducted interviews Executive Director (A1) and 6 Residents (R2-R7). On 11/6/25, the Department obtained and reviewed R1's Medication Administration Record (November 2022), Physician Orders (November 2022), and R1's Admission Agreement (dated 9/22/22). Page 1 of 3 Unsubstantiated The investigation revealed the following: Allegation: Staff did not notify responsible party of a resident's fall resulting in medical attention The detail of the complaint alleges that responsible party was not notified that R1 had fallen on 2/24/23. On 11/4/25, at 12:43 p.m., the Department interviewed the Executive Director (A1) who denied the allegation, stating that no fall was reported on 2/24/23. However, she confirmed that an unwitnessed fall did occur on 2/12/23, and that the responsible party was notified of the fall through an incident report. On 11/4/25, the Department obtained and reviewed an incident report concerning an unwitnessed fall that took place on 2/12/23. The report confirmed that appropriate notifications were made, including to the responsible party and the primary care physician. It further indicated that no head impact occurred, and no injuries were sustained. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Page 2 of 3 Allegation: Staff failed to administer resident's medications as prescribed The detail of the complaint alleges that R1’s medication was not refilled resulting in R1 missing medication. On 11/4/25, at 12:43 p.m., the Department interviewed Executive Director Marie Hill (A1), who denied the allegation, stating that there had been no report of R1 missing any medication. A1 stated that staff members are trained in medication administration and receive regular refresher training. A1 further described the facility’s process: “The doctor sends the orders to the pharmacy, where they are reviewed before being forwarded to us. We then check and double-check the orders to ensure accuracy.” On 11/5/25, between 10:00 a.m. and 12:00 p.m., the Department interviewed 6 residents (R2–R7). R1 has not resided at the facility since 10/25/24. 6 out of 6 residents reported that they consistently receive their medication on time and have never missed a dose due to staff error. On 11/6/25, the Department obtained, reviewed and evaluated R1’s Medication Administration Record (MAR) and Physicians orders for the month of November 2022 and found no discrepancies during the review period. Based on the information gathered there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today's visit. Exit interview conducted and copy of report provided. Page 3 of 3the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 18-AS-20230316164248

Allegation investigated: Facility has mold.

On November 5, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced at the facility and met with the Licensee, Maria Hill. LPA explained the reason for the visit was to provide findings for the complaint investigation. During the investigation, LPA conducted interviews, record reviews, and made observations pertaining to the listed allegation. On January 17, 2023, Community Care Licensing received a complaint alleging Facility has mold. It was reported that there was suspected mold in the activity room and room 20. It was additionally reported that a couple of weeks went by, and the suspected mold was just painted over, and there was no professional called out to test the suspected mold. Information obtained from interview with Licensee; Johnathan Thomas denied the allegation the facility had mold. The Licensee indicated there was simply water damage from the previous rains. Additionally, the Licensee stated there was a professional called out to test the suspected spots for mold. There was no mold detected at the time of the inspection. Information obtained from interviews with staff members indicated there was no information brought to their attention that there was mold detected at any time at the facility. Information received from interviews with Residents indicated they have resided at the facility during the time of the investigation and there was never a time when they were informed of there being any type of mold located in the activity room or in any room in the facility. Due to the complaint being filed anonymously, LPAs were unable to interview and obtain additional information regarding the allegation. LPA’s review of the records confirmed there was no documentation confirming there was any type of mold detected at the facility covering the investigation period. LPA’s observations confirmed there was no water damage found at the facility at the time of the unannounced visit. LPA conducted subsequent interviews with Witness, and they advised that there were no challenges or concerns with mold at the facility. Additional Witness interviewed indicated there were no concerns or issues brought to their attention regarding there being mold located at the facility. Based on information obtained from interviews, record reviews, observations, and the unavailability of relevant parties, the evidence received pertaining to the allegation, the facility has mold, has been deemed unsubstantiated. An unsubstantiated allegation means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted. A copy of this report was discussed and given to the Licensee, Maria Hill. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 5, 2025 · control 18-AS-20230117113429

Allegation investigated: Staff does not ensure resident dental care needs are being met Staff do not assist resident with transportation to the dental office

On November 5, 2025, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Loucinda Hickerson, Memory Care Director and the purpose of the visit was explained. Investigation consisted of the following: On 8/14/23 the Department conducted an unannounced initial visit to the facility to investigate the complaint allegations mentioned above. During the visit, it was determined that the complaint required further investigation. On November 5, 2025, the Department requested and received copies of the following: Staff roster (dated 10/4/25) Resident Roster (dated 10/22/25), R1 physician’s report (dated 3/17/23), Needs and Services Plan (dated 8/21/23), R1’s pre-placement appraisal (dated: 7/11/22), Dentist Authorization (dated 7/11/22), Dental hygienist report (dated 4/17/23). The Department conducted interviews with Executive Director (A1), and 6 residents (R2-R7). Page 1 of 4 Unsubstantiated The investigation revealed the following: Allegation: Staff does not ensure resident dental care needs are being met The detail of the complaint alleges that the facility is not ensuring that R1 receives needed dental care. The Department interviewed Marie Hill Executive Director (A1) who denied the allegation, stating that R1 had received dental services while he lived in the facility. A1 stated that the responsible party signed the dental authorization form to agree to receive in house dental services where the Dental Hygienist or Dentist will provide services at the facility. A1 further stated that if the dental hygienist make a referral for services outside of the facility, then they typically discuss it with the resident's family so that arraignments could be made. Lastly, A1 stated on 4/17/23, R1 saw the Dental Hygienist who made a referral, however R1 declined the service because of the expense. On 11/5/25, the Department obtained and reviewed the Dental Hygienist report (dated 4/17/23) which corroborated the Executive Director (A1) assertion that R1 did receive dental services while at the facility. Additionally, the Dental Hygiene report showed that a referral for dental services was made, but R1 stated that it was too expensive; therefore, declining the referral. Lastly, the Department reviewed dental authorization (dated 7/11/22) signed by the responsible party accepting services for R1 to be seen by dental hygienist and dentist that comes out to the facility. Page 2 of 4 On 11/5/25, between 10:00am and 12:00pm, the Department interviewed 6 residents regarding dental services offered at the facility. 6 out of 6 stated that they are offered dental services; 4 out of 6 stated that a family member make appointments for them when needed and 2 out of 6 stated that they have dentures and doesn’t use any dental services. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff do not assist resident with transportation to the dental office. The detail of the complaint alleges that “the facility does not transport R1 to the dental office, but rather a private dentist would come to the facility for all the residents.” The department interviewed Executive Director Marie Hill (A1) regarding this allegation. A1 stated, “Usually the family would transport residents to the dentist because the family needs to make decisions for the resident’s care. The facility is not authorized to make medical discussions so the family will have to be there at the dental office to make decisions for care.” On 11/5/25, the Department interviewed 6 residents regarding the allegation and of those interviewed 6 out of 6 stated that if they needed to see the dentist they would use the dentist on site, but if they needed outside services then family would transport them to the dentist. Page 3 of 4 Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today’s visit Exit interview conducted and copy of report provided. Page 4 of 4the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 18-AS-20230811133124

Allegation investigated: Resident was admitted without consent of responsible person. Staff do not distribute medications according to physician’s orders.

On November 5, 2025, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Loucinda Hickerson, Memory Care Director and the purpose of the visit was explained. Investigation consisted of the following: On 8/14/23 the Department conducted an unannounced initial visit to the facility to investigate the complaint allegations mentioned above. During the visit, it was determined that the complaint required further investigation. On November 4, 2025, the Department requested and received copies of the following: Staff roster (dated 10/4/25) Resident Roster (dated 10/22/25), R1's physician’s report (dated 3/17/23), R1's Needs and Services Plan (dated 8/21/23), R1’s pre-placement appraisal (dated: 7/11/22) admission agreement (dated:7/12/22). R1 Medication Administration Record (MAR) dated:August-September 2023, Physican's orders (dated September 2023), Staff Medication training (dated 11/29/23) and Progress notes (dated July, Aug, Sept 2023).The Department conducted interviews with 5 staff (S1-S5) and Administrator (A1). On November 5, 2025, the Department interviewed 6 residents (R2-R7). page 1 of 4 Unsubstantiated The investigation revealed the following: Allegation: Resident was admitted without consent of responsible person The detail of the complaint alleges that the resident nor his conservator sign the admission agreement. On November 4, 2025, at 12:43pm the Department interviewed Executive Director Marie Hill (A1) who denied the allegation stating the responsible party did sign the admission agreement. A1 further stated that the Residents do not sign because the facility is full memory care and they need their responsible party to sign. On November 4, 2025, between 1:00pm and 2:30pm, the Department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed 5 out of 5 could not provide any input on this allegation because they are not part of the residents' admission agreement signing process. On November 4, 2025, the Department obtained and reviewed a copy of the R1’s admission agreement which revealed that the document was signed by the responsible party and the Executive Director. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Page 2 of 4 Allegation: Staff do not distribute medications according to physician’s orders. The detail of the complaint alleges that the staff doesn’t give R1 his medication on time. On November 4, 2025, at 12:43pm, the Department interviewed Marie Hill (A1) who denied the allegation stating that there has been no report of R1 missing medication. A1 further stated that her staff are trained on medication administration and have frequent refreshers. A1 states that “the facility get the orders from the doctor, it's sent to the pharmacy first and they check orders before it is sent to us. Then we check and double check the order to make sure it is correct.” On November 4, 2025, between 1:00pm and 2:30pm, the Department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed 5 out of 5 denied allegation stating that R1’s medication was given on time and as directed by the doctor. 5 out of 5 staff state that they have had medication training. Lastly, 5 out of 5 state that missed medication is rare, but when it happens they report it to the doctor, the responsible party and to the Department via incident report. On November 5, 2025, between 10:00am and 12:00pm the Department interviewed 6 residents (R2-R7). R1 was not interviewed as R1 no longer lives at the facility as of 10/25/24. Of those interviewed 6 out of 6 stated that they receive their medication on time and they have never missed a dose due to staff not giving it. page 3 of 4 On November 4, 2025, the Department obtained, reviewed and evaluated R1’s Medication Administration Record (MAR) for the months of August-September 2023 and found no discrepancies during the review period. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today's visit. Exit interview conducted and copy of report provided. Page 4 of 4the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 18-AS-20230809121001

Type of visit: Required - 1 Year

On 09/09/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Administrator, Marie Hill who was informed of the purpose of the visit. LPA toured the facility with Administrator Hill. The facility is made up of one (1) building designated for memory care. The facility is licensed for 96 non-ambulatory residents of which 10 may be bedridden. The facility also has an approved hospice waiver for 35 residents and LPA was informed there are currently 12 residents on hospice. The facility has an activity room, several dining areas, and outside shaded seating available for resident use. Indoor and outdoor passageways are free of obstruction. There are no bodies of water on the premises. LPA observed fire alarm systems, carbon monoxide detectors and charged fire extinguishers mounted throughout the building. LPA toured the kitchen and obseved the facility met Departmental requirements for a two-day supply of perishable foods and seven-day supply of non-perishable food items. Food is stored in a safe and healthful manner. Medications are stored inside medication carts in the locked medication room, which only accessible to authorized personnel such as medication technicians. Cleaning solutions are stored in the housekeepers' lockers that are secured with master locks inside the locked laundry room. Resident files reviewed had updated physician's reports and signed admission agreements. Staff files reviewed had the required records. LPA reviewed the facility's Fire/Internal Disaster Drill noting their last fire drill was conducted on 07/22/2025. Long Term Care Ombudsman's contact information, complaint procedures, resident's personal rights and emergency disaster plan were visibly posted near the front entrance. No deficiencies were issued during today's visit. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Hill.the state’s words, verbatim · CDSS document, Sep 9, 2025

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-ambulatory, facility staff and R1’s resident representative stated R1 was Unsubstantiated still ambulatory and walked around and out of the facility without an assistive device. R1’s resident assessments, dated 01/23/2022 and 02/19/2023, both indicated a fall risk service plan with safety checks four times per shift and as needed for R1. A review of the medical records and facility nursing notes revealed that on 05/31/2022, R1 complained of pain in left arm and staff noticed slight swelling in R1’s left wrist. R1’s resident representative was immediately notified and R1 was sent to the hospital for evaluation. According to the medical records, the paramedics stated R1 was pushed off the bed by another resident and fell onto their outstretched arms; patient complained of bilateral wrist pain. X-rays revealed bilateral distal radius fractures. R1 was diagnosed with left and right wrist fractures with no surgery performed. The facility nursing notes, dated 05/31/2022, list “aggressive act victim; R1 noted to have limited range of motion to left arm, slight swelling noted to wrist, hand appears to have no swelling, wrist tender to touch….. Received update from hospital, R1 has fracture to left wrist”. Due to R1’s cognitive impairment, R1 was unable to explain how R1 injured their wrist. On 08/20/2022, R1 fell to the ground when R1 ran into another resident. R1 was evaluated by the facility med tech where R1 initially complained of pain in wrist and arm (nursing notes do not indicate which side). R1 had normal range of motion and stated, “my arm is not broken, if it was, I would be screaming my head off.” R1 was not sent out to the hospital and was treated at the facility with ice packs and monitored. No further complaints of pain were reported. On 11/20/2023, R1 complained of right wrist pain when staff were assisting R1 to get undressed for bed. There was no witnessed fall and R1 was not found on the floor. R1 was assessed and sent to the hospital to be evaluated. During R1’s examination, R1 had x-rays done on both shoulders and right wrist. The left shoulder showed no fractures. The right shoulder showed chronic appearing fractures. The right wrist showed chronic appearing deformity of the distal radius with positive ulnar variances. The bones are demineralized. No acute fracture is seen. The records indicated “chronic injuries that are well healing”. The hospital discharge paperwork, dated 11/21/2023, states “we will discharge the patient home with right wrist and right shoulder fractures which appear to be chronic with a plan for orthopedic follow-up and PCP follow-up”. The 11/21/2023 facility nursing notes revealed the hospital called to give update on R1 and stated R1 seen for right wrist pain had x-ray done on right wrist and shoulder and showed chronic fractures of right wrist and shoulder. An interview with the physician who examined R1 at the hospital on 11/20/2023 was conducted. R1’s x-rays and medical history charts were reviewed. Although R1 did not show any new fractures during the visit, R1 had chronic appearing fractures in R1’s wrists, shoulders and ribs from other past visits. The physician said they could not determine the age of the chronic appearing fractures and they all appeared to be healed or healing. The physician said this and the fact that R1 came to the hospital from an assisted living facility with old trash bags concealed in R1’s pants gave concerns of neglect at the facility. The physician spoke with R1’s resident representative who informed the physician it is normal behavior for R1 to conceal items in R1’s clothing and it is part of R1’s diagnosed behavior. R1’s resident representative also told the physician that they believe the staff at the facility treat R1 well and has no concerns for R1’s care at the facility. During the course of the investigation, the Department was informed by R1’s resident representative that R1 suffered two falls before moving into Vista Del Lago, one at a board and care facility where R1 fractured left shoulder and left wrist, and one at home where R1 fractured several ribs. The physician stated that R1’s resident representative did not provide this history to them during their conversation, and it explains many of the chronic appearing fractures R1 showed during his examination. The Department’s investigation revealed facility staff acted appropriately during each incident and advised R1’s resident representative of R1’s condition and obtained R1 needed medical care. Since R1’s return from the hospital on 11/21/2023, staff have been directed to do increased safety checks, home health physical therapy has been ordered and the Resident Services Director said R1’s care plan will be reassessed once R1 is seen by R1’s physician. During the investigation, no evidence or statements were found to corroborate neglect or lack of supervision of R1. Therefore, the allegation is deemed Unsubstantiated at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. Exit interview conducted, copy of this report was reviewed and provide to Marie Hill, Executive Director.the 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. Unsubstantiated LPA conducted an interview with the reporting party who reported the following information. Care Coordination Agencies (CCAs) collaborate with a resident, their responsible person and assisted living facility to enroll the resident onto the ALW program. Vista del Lago Business Office Director (BOD), Jennifer Rios verbally agreed to assume responsibility to assist R1 with ALW program enrollment. However, in fall 2024 BOD failed to follow up and provide requested information to R1’s CCA, which resulted in R1 losing their place in the ALW program waitlist. LPA conducted an interview with BOD Rios who refuted the allegations and reported the following information. BOD denied ever assuming responsibility to enroll R1 in the ALW program as it is outside of the scope of their duties. R1’s CCA requested resident records from the facility; however, the request was accidentally overlooked by facility staff and R1’s CCA/responsible person did not follow up on the request prior to R1 being dropped from the ALW program waitlist. Administrator Hill was also interviewed and reported the following information. Although the facility collaborates with CCAs/responsible persons and provides any requested resident records to aid in the ALW program enrollment, it is not the facility’s responsibility to enroll any resident in the ALW program. The facility is only responsible for providing care and supervision funded by ALW. Furthermore, the facility did not act with malice and there is no financial incentive to sabotage R1’s ALW program enrollment. Administrator Hill added they believe R1 receives the required care and supervision at the facility and the facility has never restricted R1 or any other resident from pursuing other housing options. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report and Confidential Names list (LIC 811) was reviewed and provided to Administrator Hill.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 18-AS-20250723140804

Type of visit: Case Management - Incident

On 6/16/2025, Licensing Program Analyst Janette Romero conducted an unannounced case management visit to the facility to follow up on an Unusual Incident/Injury Report (LIC 624) submitted by the facility reporting an incident involving Resident 1 (R1). LPA met with Administrator, Marie Hill who was informed of the purpose of the visit. The LIC 624 reported the following information. On 2/28/2025, R1 was found in their room with a container of Powdered Chlorine Bleach Cleaner (PCBC). R1 applied the cleaner onto their hand and face and a "small" amount was found in their cup of water. When asked if consumed, R1 initially reported they did and then denied doing so. The facility called an ambulance and R1 insisted on having dinner. R1 ate their dinner in the dining room with no complaints or reports of pain/discomfort. R1 was taken to the hospital via non-emergency medical transport and later returned to the facility with no new findings. Administrator Hill was interviewed and reported the following information. The disinfectants/cleaning solutions are stored in the locked laundry room inside every housekeeper's locker. The lockers are individually secured with a keyed padlock. When in use, housekeepers transfer the disinfectants/cleaning solutions onto their mobile carts, which also have a locking mechanism to make it inaccessible to the residents in care. Hospital records indicate the correct date of the incident is 2/27/2025 not 2/28/2025. On 2/27/2025, the incident took place as documented in the LIC 624 noted above. Housekeeping Staff 1 (S1) was assigned to clean R1's bedroom. Administrator Hill interviewed S1 regarding the incident and received following information. S1 used the PCBC to clean R1's room. After cleaning R1's room, S1 only secured one (1) PCBC as they did not realize they had two (2) PCBCs in their cart. S1 admitted to accidentally leaving one (1) PCBC unattended in R1's bedroom, which made it accessible to R1. Administrator Hill was made aware of the incident when R1 was having dinner. Facility staff measured R1's vital which were not abnormal and R1 did not exhibit any signs of distress. Therefore, the facility arranged for non-emergency medical transportation to the hospital. During today's visit, LPA toured the facility and observed the 21 ounce containers of PCBC used by housekeepers. LPA also observed the lockers with padlocks, mobile carts with locks, and laundry room which required a keyed fob entry. LPA observed the ounce PCBC container titled, "Cleanser Powerful Cleaning Action with Chlorine Bleach" and warns users to use protective gloves and eye protection as it causes skin, respiratory, and serious eye irritation. LPA reviewed R1's Physician's Report dated 8/27/2024 noting R1 exhibits confusion, is oriented to self only, and does not have the capacity to leave the facility unassisted, manage their own cash resources or medications. During today's visit, no imminent health or safety concerns were observed. Based on the aforementioned, the facility will be cited and civil penalties will be assessed. An exit interview was conducted, and a copy of this report, LIC 809-D, LIC 412FC, and Confidential Names list (LIC 811) were reviewed and provided to Administrator Hill.the state’s words, verbatim · CDSS document, Jun 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jun 20, 2025

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, R1 was observed with a container of powdered chlorine bleach cleaner. R1 applied the cleaner to hand, face, and in their cup of water. When asked if consumed, R1 initially reported they did. The incident report documents R1 was sent to the hospital via non emergency medical transport rather than activating emergency services, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 16, 2025

Plan of correction: Administrator Hill reported the facility will receive training from an outside vendor regarding regulation 87465 Incidental Medical and Dental Care by close of business on 6/18/2025. POC will be emailed to LPA by close of business on 6/20/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87309(a) · Plan of correction due date: Jun 20, 2025

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This poses a potential health and safety risk to residents in care. Based on interviews conducted and records reviewed, the facility failed to secure a powdered cleaning solution by leaving a container unattended and accessible to R1. R1 then applied the cleaner onto their hand, face and in their cup of water. When asked if consumed, R1 initially reported they did. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 16, 2025

Plan of correction: Administrator Hill reported S1 was counseled regarding the incident and terminated on 2/28/2025. LPA observed the facility's Counseling/Disciplinary Notice for S1 noting their termination of employment effective 2/28/2025. Administrator Hill added the facility conducted an in-service training on 3/3/2025 and 3/13/2025 regarding safety practices for hazardous and potentially toxic substances including cleaning products. LPA reviewed (2) staff sign-in sheets for the reported trainings. POC met.

Type of visit: Case Management - Deficiencies

On 12/27/2024, Licensing Program Analyst (LPA), Janette Romero conducted an unannounced case management visit to address a deficiency observed relative to the Unusual Incident/Injury Report (LIC 624) submitted by the facility. LPA met with Assistant Resident Services Director (ARSD), Loucida Hickerson who was informed of the purpose of the visit. On 12/2/2024, the Department received the LIC 624 reporting Staff 1 (S1) was observed intimidating and bullying Resident 1, Resident 2, and Resident 3 at the facility on 11/29/2024. The LIC 624 noted S1 was placed on administrative leave, escorted out of the building, and is not scheduled to return to work in the facility. The LIC 624 added law enforcement was contacted and the facility met all reporting requirements in a timely manner. Written witness statements were also provided to the Riverside Regional Office as well. LPA reviewed video footage inside the facility's common areas and observed S1 kicking, pushing, using profanity, stepping on resident's feet, and snapping a towel in a resident's face. Although the facility took appropriate actions upon learning of the incidents, multiple residents' personal rights were violated and some were physically abused by S1 while in the facility's care. As a result, the facility will be cited. LPA provided ARSD Hickerson with a copy of Title 22, Division 6, Chapter 8 regulation numbers 87468, 87468.1, and 87468.2 which detail residents' personal rights for the facility to keep as reference. An exit interview was conducted and a copy of this report was reviewed and provided to ARSD Hickerson along with a Confidential Names list (LIC811) and Appeal Rights.the state’s words, verbatim · CDSS document, Dec 27, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jan 10, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Based on interviews conducted, records and video footage reviewed, S1 physically and psychologically abused multiple residents on November 25, 2024 and November 29, 2024. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 27, 2024

Plan of correction: Licensee reported the facility will conduct an in-service staff training regarding personal rights of all residents and generate a checklist to include documentation of a reference check for new employees. POC due to LPA by close of business by 1/10/2025. *This is an amended version of the original report

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 activate emergency services. RSD explained facility staff reported R1 did not express pain and RSD viewed the photograph, and the wound was not actively bleeding. Therefore in RSD's opinion, facility staff could manage the wound and R1 did not require emergency services. RSD reported the source of the injury is unknown. Substantiated RSD reported they instructed facility staff to clean the wound, put antibiotic ointment and bandage it. RSD reported the facility contacted R1's physician's office at San Diego PACE and requested home health services for wound care while the facility's licensed vocational nurses treated the wound and changed the dressing on a daily basis. RSD reported Mismo Dermatology assessed R1 on 11/19/2024. LPA contacted Mismo Dermatology who reported a Physician's Assistant (PA) was at the facility when staff requested they assess R1's wound. Mismo Dermatology reported the PA assessed the wound and determined it was too late for R1 to receive stitches. RSD reported R1's Responsible Person (RP) was notified of the wound and declined emergency services for R1. LPA conducted an interview with R1's RP who reported they were notified of the wound but RSD minimized the severity of the wound and reiterated the wound could be managed by facility staff. R1's RP reported facility staff never offered them the option to send R1 to the hospital. R1's RP reported when R1's family observed the wound in person, they were concerned with the severity of the wound and contacted San Diego PACE who requested to see R1 in their office. On 11/20/2024, R1's RP transported R1 to San Diego PACE to address the wound. LPA reviewed R1’s Medical Visit Summary from San Diego PACE noting on 11/20/2024 R1 visited their physician, at San Diego PACE's request, and was observed with an uncovered open wound measuring 6 centimeters by 2 centimeters with no discharge, edges with eschar tissue, no erythema around the wound, and subcutaneous tissue exposed. The MVS noted the wound required stitches and R1 was referred to the emergency department following their doctor’s visit. Based on interviews conducted, and records reviewed, 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 being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Hill along with a Confidential Names list (LIC 811) and Appeal Rights.the state’s words, verbatim · CDSS document, Dec 11, 2024 · control 18-AS-20241125114737

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 11, 2024

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, R1 sustained a wound that required stitches and RSD instructed facility staff to not activate emergency services and treat the wound instead. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Licensee reported the facility will conduct an all staff in-service training regarding incidental medical care. POC to be submitted to LPA by close of business on 12/20/2024.

Type of visit: Case Management - Health Checks

On 12/6/2024, Licensing Program Analyst (LPA), Janette Romero conducted an unannounced health and safety visit to the facility to follow up on an Unusual Incident/Injury Report (LIC 624) submitted to the Department reporting incidents that occurred in the facility on 11/29/2024, involving Resident 1, Resident 2, Resident 3 and Resident 4. PA met with Administrator, Marie Hill who was informed of the purpose of the visit. LPA toured the facility, reviewed and requested video footage, and copies of pertinent records. The requested documentation will be emailed to LPA by close of business on 12/9/2024. During the visit, LPA observed the facility has working utilities along with a two-day supply of perishable food and seven-day supply of non-perishable food items. No deficiencies were cited during today's visit. No imminent health or safety concerned were observed during the tour. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Hill.the state’s words, verbatim · CDSS document, Dec 6, 2024

Type of visit: Case Management - Health Checks

On 12/6/2024, Licensing Program Analyst (LPA), Janette Romero conducted an unannounced health and safety visit to the facility to follow up on an Unusual Incident/Injury Report (LIC 624) submitted by facility to the Department reporting an incident on 12/2/2024 involving Resident 1. LPA met with Administrator, Marie Hill who was informed of the purpose of the visit. LPA toured the facility, conducted interviews, and requested records. The requested documentation will be emailed to LPA by close of business on 12/9/2024. During the tour, LPA observed the facility has working utilities along with a two-day supply of perishable food and seven-day supply of non-perishable food items. No deficiencies were cited during today's visit. No imminent health or safety concerns were observed. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Hill.the state’s words, verbatim · CDSS document, Dec 6, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Executive Director Marie Hill and Resident Service Director Priscilla Bermudas who was informed of the purpose of the visit. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies, detergents, and the sharp and dangerous objects were locked and inaccessible to the residents in the facility's janitorial and maintenance supply rooms. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector, carbon monoxide, and facility sprinkler system was operational and is maintained annually. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA was informed the facility receives multiple food deliveries a week. LPA reviewed four (4) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed, and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. The listed administrator possesses a current administrator's certificate. LPA observed medications are kept locked and inaccessible to residents in the medication room. LPA observed a MedTech getting ready to conduct blood glucose test for two (2) residents. Staff document medication administration on the facility's electronic Medication Administration Record (eMAR). LPA observed Medications prescribed to residents and found all medication listed on eMARS and all required labeling was found to be in place. Facility has an updated emergency and disaster plan and Infection Control plan. LPA observed all facility exits were clear from obstructions. Facility has a working delayed egress system on the exit doors. LPA observed emergency supplies and first aid kit with all required items. Facility contained multiple charged fire extinguishers located throughout the facility. Facility conducts monthly disaster drills with the last drill being performed on 09/05/2024. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Executive Director Hill.the state’s words, verbatim · CDSS document, Sep 23, 2024

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 R1’s physician. Interview with Staff One (S1) reported R1 receives in total five shots of insulin each day, two in the morning, one in the afternoon, and two in the evening. Unfounded Interview with R1 reported they receive their insulin in the morning at 8am, in the afternoon at 12am, and in the evening at 4pm. Interview with Staff Two (S2) revealed R1 receives two types of insulin shots in the morning, one in the afternoon, and two types of insulin at dinner. S2 reported staff check R1’s glucose three times a day before administering insulin so R1 can receive the correct dosage of units/ml of insulin. This agency has investigated the complaint alleging “Staff failed to ensure resident's insulin orders were followed”. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to Executive Director Hill.the 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 (MAR) revealed on 06/03/2024, 06/10/2024, 06/17/2024, and 06/24/2024 staff have been conducting blood glucose checks and recording as directed. Unfounded Interview with R1 revealed staff have been following physician’s orders and have been checking R1’s blood sugar every Monday. This agency has investigated the complaint alleging “Staff are not ensuring that insulin is being administered in a safe manner”. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to Executive Director Hill.the state’s words, verbatim · CDSS document, Aug 26, 2024 · control 18-AS-20240619165645

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sara Martinez made an unannounced visit to the facility. The purpose of the visit was to conduct interviews with staff regarding a complaint that is related/associated with this facility. LPA was greeted and granted entry by Priscilla Bermudes Resident Services Director, where LPA explained the purpose of her visit. No heath and safety concerns were observed at the time of LPAs visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Bermudes.the state’s words, verbatim · CDSS document, May 22, 2024

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 incontinence. On 11/02/20 a medical professional observed R1 to be unkempt, appeared as though they hadn’t showered in a while as their hair was dirty, and there was black dirt on their feet. Continued on an LIC 9099C Substantiated The medical professional also observed R1 was favoring the left side of their body due to a painful Stage II pressure injury located on their right heel. The Medical professional’s interview confirmed they contacted the facility regarding the pressure injury, but the facility stated they did not have knowledge. The facility provided basic services to R1 that included observations of R1. R1’s shower schedule for November 2020 reflected initials on the days R1 was provided showers. On 11/17/20, 11/20/20, 11/24/20, and 11/27/20 there were no initials to verify showers were provided or documentation to indicate R1 refused showers. The facility is required to meet the basic needs of the residents to include ensuring the residents are kept clean. Facility’s documentation of bathroom assistance reflected it was PRN, as needed. However, staff initials verified they assisted R1 with bathroom assistance for eight (8) of the thirty (30) days in November 2020, which indicated R1 required assistance. Staff interviews confirmed R1 was a full assist with toileting and diapers. Further staff interviews revealed finding R1 in soiled diapers on multiple occasions. Outside source interviews confirmed observing R1’s needs not being met due to being unkempt with dirty hair and black dirt on their feet. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Marie Hill whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1] R1’s medical record reflected they were prescribed a specific pain medication on 10/16/20, a PRN, as needed. A review of R1’s Medication Administration Records (MARs) for October 2020 indicated the medication was dispensed on 10/17/20 for moderate pain. MARs for November 2020 indicated the specific PRN medication was dispensed on 11/02/20 for moderate pain and 11/06/20 for severe pain. The facility was dispensing the medication as needed. Outside source interviews revealed a medical professional contacted the facility to inquire about the pain medication being dispensed. The medical professional reported the facility stated R1 was not complaining of pain, and it was unknown if staff were asking R1 if they were in pain. According to medication documentation, the licensee followed the physician’s order and provided as PRN, as needed. Staff interviews confirmed medications were dispensed as prescribed. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Marie Hill whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 08-AS-20201106075652

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(b) · Plan of correction due date: Apr 25, 2024

Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services:(b) Assistance with instrumental activities of daily living in the combinations which meet the needs of residents. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure resident needs were met for 1 out of 89 residents in care [R1] which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 18, 2024

Plan of correction: Executive Director provided recent proof of training regarding caregiver job description, caregiver training checklist to include activities of daily living and observations of residents. In addition, the facility has another training scheduled for 04/23/24 and will be ongoing monthly. POC corrected.

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. Interview with Resident Service Coordinator Priscilla Bermudas revealed R1 was deemed a fall risk and staff are instructed to perform safety checks every 2 hours and R1’s bedroom door is always open so staff can continuously check on R1. Unsubstantiated Interview with staff confirmed safety checks were performed for R1 throughout the day and night. There is no clear indication that the facility was not providing proper care and supervision during the time of each unwitnessed falls. Therefore based on interviews and record review, the allegation “Staff’s lack of supervision resulted in resident sustaining multiple falls and hospitalization” has been deemed unsubstantiated at this time. Regarding the allegation “Staff left resident soiled on the floor” it was reported R1 was left on the floor soiled and does not receive amble care. Interview with R1’s responsible party revealed during the unwitnessed fall on 01/04/2024, R1 had soiled himself and the caregivers who were present during the fall did not assist R1 with cleaning R1 up. Interview with staff revealed most of R1’s falls occurred while ambulating to the bathroom. Staff would observe if R1 had soiled themselves and would assist with changing and cleaning R1 or R1 would request assistance from staff to help clean up. Facility staff notes for R1’s falls do not notate if resident had soiled themselves during the fall. Record review of R1’s file reveals R1 maintains independence and does not require assistance for toileting. R1 requires staff assistance for personal hygiene. Therefore based on the information obtained, there is not enough evidence that staff left resident soiled on the floor. Therefore, the allegation has been deemed unsubstantiated at this time. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED. An exit interview was conducted where a copy of this report was discussed and provided to Executive Director Hill.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 injuries from the interaction for both residents. R1 stated R2 never touched or sexually assaulted R1 during the interaction. Record review of R2’s Needs and Service Plan revealed R2 has behaviors of exhibiting inappropriate sexual behaviors. Unsubstantiated LPA inquired about R2’s previous inappropriate sexual behaviors with Resident Service Director Priscilla Bermudes and it was revealed R2 is verbally inappropriate and will make sexually inappropriate statements to staff and residents. Bermudes stated R2 has never touched or harmed a resident. Therefore, based on interviews and record review, there was not enough information to corroborate the alleged allegation, the allegation “Resident was sexually assaulted while in care” has been deemed unsubstantiated at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted where a copy of this report was discussed and provided to Executive Director Hill.the 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. Unsubstantiated According to allegation, three weeks prior to November 24, 2020, R1 was dropped by an unnamed caregiver during a night shift. Interview with staff present on or around the timeframe mentioned stated they were unaware of R1 being dropped. Interview with outside source revealed that there were no instances of R1 being dropped. Interview with outside source also revealed that there was no injury on R1 to determine R1 was dropped. Records collected did not reveal any additional information to corroborate allegation. It was also alleged that facility staff did not report R1 being dropped to R1’s responsible party. Interviews with staff present on or around the timeframe mentioned stated they were unaware of R1 being dropped therefore it was not reported. Interview with outside source revealed there was no evidence to corroborate resident was dropped. Additionally, there were no records available to corroborate allegation. Based on Department’s interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Marie Hill , to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 13, 2024 · control 08-AS-20201124123344