Gardens At Escondido

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

Allegation investigated: Due to staff neglect, resident sustained a burn requiring hospitalization.

On 09/22/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation noted above. LPA met with Monica Flores, Executive Director and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, and the investigation consisted of observations, interviews and records review. On 07/13/2023 Community Care Licensing received a complaint alleging due to staff neglect, resident sustained a burn requiring hospitalization. Resident #1 (R1) was admitted to the facility on 06/15/2023. On 07/13/2023 during medication pass, R1 was found inside their bedroom in a frog-like position facing downward at the foot of their bed. Staff #1 (S1) checked R1’s vitals and observed R1 to have redness around their calf of their legs, but no blistering. Emergency Services were activated and R1 was sent out and admitted to a local hospital from 07/13/2023 to 08/02/2023. Unfoundedthe state’s words, verbatim · CDSS document, Sep 22, 2025 · control 18-AS-20230713151454

Allegation investigated: Licensee did not allow resident access to telephone. Licensee did not allow resident to leave facility.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Monica Flores. On 05/16/2025 it was alleged that Licensee did not allow Resident 1 (R1) access to a telephone and did not allow R1 to leave the facility. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, residents, outside sources, and records review. Staff interviews consistently revealed that R1 was allowed to receive phone calls from outside parties and family and that the facility assisted with the communication. Additionally staff informed that R1 had a personal cell phone in their possession that they used, and sometimes misplaced around the facility. Outside source interviews did not corroborate the allegation, as outside sources informed that they had directly observed the facility assisting R1 wthe state’s words, verbatim · CDSS document, May 20, 2025 · control 08-AS-20250516142641

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

Allegation investigated: Uncleared staff caring for residents.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to initiate and deliver findings for a complaint investigation regarding the above-mentioned allegation. LPA identified themselves and met with Executive Director Monica Flores, to discuss the purpose of the visit and elements of the complaint. During the visit LPA collected facility records, and interviewed staff. On 03/28/2025 it was alleged that an uncleared staff was caring for residents due to being underage. Staff interviews revealed that the staff in question had a valid work permit, approved by their school, to work at the facility during the summer of 2024. Review of facility records corroborated staff statements, showing that the staff member had the legal background check documents and records in their file. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANthe state’s words, verbatim · CDSS document, Apr 4, 2025 · control 08-AS-20250328163548

Allegation investigated: Staff yells at residents.

On March 30, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent visit to gather information regarding the above allegation. LPA met with Philip Green, the Food Services Director, and explained the purpose of the visit. LPA contacted Monica Flores, Executive Director, and informed Flores of the intention of the visit. The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #7 (S1-S7) and resident members #1 to #9 (R1-R9). List of documents reviewed/obtained Resident Roster (dated 09/28/23 & 03/29/25), Staff Roster (dated 10/11/23 & 03/29/25), (R1)'s Physicians Report LIC 602 (dated 06/01/22 and 11/02/22), Residence and Care Agreement (dated 06/06/22), Resident Assessment (dated 06/03/22), Identification and Emergency Information LIC 601 (dated 06/02/22), and other pertinent documents associatedthe state’s words, verbatim · CDSS document, Mar 30, 2025 · control 18-AS-20231006100625

Allegation investigated: Staff are not assisting resident with transportation. Staff are not adhering to the admission agreement.

On March 29, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent visit to gather information regarding the above allegations. LPA met with Monica Flores, Executive Director, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #7 (S1-S7) and resident members #1 to #9 (R1-R9). List of documents reviewed/obtained Resident Roster (dated 09/28/23 & 03/29/25), Staff Roster (dated 10/11/23 & 03/29/25), (R1)'s Physicians Report LIC 602 (dated 06/01/22 and 11/02/22), Residence and Care Agreement (dated 06/06/22), Resident Assessment (dated 06/03/22), Identification and Emergency Information LIC 601 (dated 06/02/22), and other pertinent documents associated with this complaint. (Evaluation Report continues LIC 9099-C) Thisthe state’s words, verbatim · CDSS document, Mar 29, 2025 · control 18-AS-20230925083814

Allegation investigated: Licensee did not ensure provision of toilet paper. Licensee did not administer medication as prescribed

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation(s). LPA introduced themselves and disclosed the purpose of the visit to Executive Director Angela Scott-Kapiloff. On 04/25/2024 it was alleged that Licensee did not ensure provision of toilet paper for residents, and Licensee did not administer medication as prescribed. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, and outside sources. Staff members consistently referred to an existing facility policy that limited residents to 2 rolls of toilet paper per week. Staff stated that when a resident needs more than this, it is the family's responsibility to provide the additional toilet paper. Interviews were mixed regarding how strict the policy actually was, and some staff were unsure of the exact limit, offering that residents received 1 or 3 rolthe state’s words, verbatim · CDSS document, Mar 18, 2025 · control 08-AS-20240425123147

Allegation investigated: Staff physically abused resident.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Angela Scott-Kapiloff. On 02/28/25 it was alleged that a staff member (S2) physically abused a resident (R1). The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff members interviewed unanimously denied ever seeing another staff member hit a resident. Staff interviews revealed that R1 was experiencing a change in condition, resulting in a delusion that they were being hit and harassed by S2 and two other parties. The accused staff member, S2, was aware of the accusation and stated that they elevated it up their chain of command, providing proof that they had been promoted to a new position, resulting them not seeing R1 often. S2 also informed that were not wthe state’s words, verbatim · CDSS document, Mar 18, 2025 · control 08-AS-20250228102124

Allegation investigated: Licensee permanently changed resident's accomodations without required notice. Licensee did not answer communications from a representative promptly.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Resident Services Director Nae Brownell. On 12/09/2024 it was alleged that Licensee permanently changed a resident's accommodations without required notice and Licensee did not answer communications from a representative promptly. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, outside sources, and LPA direct observations. Regarding the allegation, "Licensee permanently changed resident's accommodations without required notice", it was alleged that a resident was permanently moved to a different room in the facility without the required written 30-day notice to the responsible party. Staff interviews corroborated the allegation, informing that residents on the second floor ofthe state’s words, verbatim · CDSS document, Mar 7, 2025 · control 08-AS-20241209163025

Allegation investigated: Staff did not answer resident's call button in a timely manner. Licensee did not ensure chemicals were properly stored.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation(s). LPA introduced themselves and disclosed the purpose of the visit to Resident Services Director Nae Brownell. On 01/23/2025 it was alleged that staff did not answer resident's call button in a timely manner and Licensee did not ensure chemicals were properly stored. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations. Staff interviews corroborated the allegation, staff informing that specific days of the week had particularly low staff, resulting in long resident wait times. Staff informed of observing approximately 40-minute wait times for resident pendants to be responded to. Staff informed that residents complained to them about the extended wait times, expressing concern about not beingthe state’s words, verbatim · CDSS document, Mar 7, 2025 · control 08-AS-20250123111801

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

Allegation investigated: Lack of supervision resulted in resident elopement.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Angela Scott-Kapiloff. On 12/11/24 it was alleged that the Licensee's lack of supervision for Resident 1 (R1) resulted in R1 eloping from the facility. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff interviews consistently showed that R1 was almost completely independent and lived in the Assisted Living section of the building. The interviews did not corroborate that staff provided less supervision than was necessary for R1, as interviews showed that staff were aware that R1 was not able to leave the building unassisted, and redirected R1 when R1 attempted to leave by themselves earlier the day of the incident. Interviews revealed that staff were unawthe state’s words, verbatim · CDSS document, Feb 21, 2025 · control 08-AS-20241211132531

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

Allegation investigated: Licensee did not follow infection control notification policy.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to initiate an investigation regarding the above complaint allegation and deliver findings. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Angela Scott-Kapiloff. LPA was away from the facility from 1:15pm to 2:15pm. On 01/06/2025 it was alleged that the Licensee did not follow the facility's infection control notification policy. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, outside sources, and records review. Staff interviews revealed that the facility did not experience a Covid-19 outbreak during the timeframe of complaint, therefore community notification was not required. Staff informed that two (2) Covid-19 cases existed concurrently at the facility, which did not reach the level of outbreak status. (Continued on LIC9099-p.2) Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 15, 2025 · control 08-AS-20250106152332

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

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

Allegation investigated: Licensee did not adhere to the admission agreement Licensee did not assist resident(s) with transportation

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the finding on the above mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Executive Director Angela Scott-Kapiloff During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents and outside sources. It was alleged that the Licensee did not adhere to the admission agreement. The Reporting Party (RP) specified that the licensee did not provide basic cable and that the cable bill was not paid therefore the cable television was not working. LPA Domingo reviewed the entire admission agreement and basic cable television was no working. LPA Domingo reviewed the entire admission agreement and basic cable (Continue on LIC9099C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 11, 2024 · control 08-AS-20240405151000

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

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