Vista Gardens Memory Care

Type of visit: Case Management - Other

Licensing Program Manager (LPM), Jazmond Harris, conducted a visit to the facility to deliver an amended page from a report. LPM met with Executive Director and explained the purpose of the visit. Executive Director provided requested documents. An exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 4, 2026

Allegation investigated: Staff neglect resulted in resident (Resident #1) sustaining multiple burns. Staff did not seek timely medical attention for resident (Resident #1).

On September 02, 2026, Licensing Program Analyst (LPA), Venus Mixson conducted an unannounced visit to the facility in order to deliver the findings for the above listed allegations. LPA met with Administrator, Caroline Senteno and informed them of the purpose for the visit. During the course of the investigation, interviews were conducted with staff and residents, review of documentation, and observations. On September 3, 2025, Community Care Licensing (CCL), received a complaint alleging staff neglect resulted in resident sustaining multiple burns and staff did not seek timely medical attention for resident. It was alleged Resident #1 (R1) sustained 2nd and 3rd degree burns due to being left unattended outside in the sun. Facility staff interviews revealed R1 was left outside in the sun by a caregiver. On 08/30/2025, at approximately 8:30 AM, a caregiver was supervising R1 on the patio. Interviews revealed the caregiver left on a break and advised two other caregivers that R1 was outsider was then left for approximately an hour and thirty minutes in the direct sunlight and there was no information obtained that a caregiver supervised R1 during that time. Staff interviews revealed that staff reviewed a copy of the facility’s surveillance footage and they reported seeing a caregiver transporting R1 to the patio and leaving R1 on the patio at approximately 10:17am. Then the footage shows the same caregiver returning at approximately 11:14am. The Department was not provided a copy of the surveillance footage because the Department was informed the footage had been deleted. Hospice records were obtained. The Hospice Patient Visit Record dated 08/30/2025 revealed “Pt fell asleep outside in direct sun unknown amount of time new 2nd degree burn to upper back neck 3-4 fluid blisters to upper back. R should blister open clear fluid draining.” Substantiated It was also alleged R1 was put back in bed without medical attention after they were found outside. Information obtained from facility staff confirmed R1 was not transported to the hospital. It was stated that on 08/30/2025, the hospice agency was contacted by facility staff and they conducted a visit to evaluate R1’s injuries. Staff interviews revealed that hospice staff advised R1 needed to be transported to be further evaluated. Facility staff reported to the Department that an additional party was contacted and this additional party refused to allow the further evaluation. An interview with R1 was attempted, but no information was able to be obtained due to their cognitive ability. Interviews conducted with the additional party revealed they did decline further evaluation however, this additional party reported that this decision based on being advised that R1 sustained a sunburn and there were no concerns. They also reported that the severity of the injury was not communicated to them. Based on information obtained, the allegations that staff neglect resulted in resident sustaining multiple burns and staff did not seek timely medical attention for resident have met the preponderance of evidence standard. Therefore, the above allegations are found to be SUBSTANTIATED. An Immediate Civil Penalty of $500 is being assessed today. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department. An exit interview was conducted where this report, LIC9099D, LIC421IM, LIC 811, and appeal rights were discussed and provided to Administrator, Caroline Senteno.the state’s words, verbatim · CDSS document, Sep 2, 2026 · control 18-AS-20250903102337

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 3, 2026

87411(a) Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and record reviews, R1 sustained 2nd and 3rd degree burns. R1 was left unattended, outside in the sun, which posed an immediate Health & Safety risk.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Llicensee has agreed to provide training on "Safety Check & Communication." Proof of training to be provided to the Licensing Agency by due date. *This is an amended version of an original 9099-D issued on 09/02/2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Sep 4, 2026

87465(a)(1) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan should encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews, facility staff did not seek medical treatment for R1’s burns and blisters, despite hospice staff advising them to seek further evaluation, which posed an immediate Health & Safety risk.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Licensee provided training to staff on Supervision of Residents in Extreme Weather Conitions. Proof of training was provided to the Licensing Agency.

Type of visit: Required - 1 Year

On July 15, 2026, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Annual Inspection and met with the Administrator, Caroline Senteno. The facility file review was conducted at the Regional Office, and additional records were requested and reviewed on site. The facility is licensed for 99 Elderly Adult Residents and is currently operating at capacity of 98. The facility is operating within the scope of the license. For a 740 facility type. LPA Mixson toured the facility, along with the Administrator and made observations pertaining to the required annual visit. LPA inspected the facility inside and outside. There were no obstructions or debris observed to the indoor or outdoor passageways at the time of this visit. There were no bodies of water observed on the premises. The facility is a two story structure with multiple entry and exits, the exits observed during this annual visit were seen to be clear, there were no observed health or safety challenges seen at the present. The facility phone number is (760) 295-3900 and it is operable. LPA Mixson observed a sampling of the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility restrooms, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the PUB 475. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked. Medications were observed to be locked and inaccessible to residents. LPA saw that there was a sufficient supply of medication for residents. The overall facility is clean; the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit. Administrator informed LPA there were safety lights for night throughout the facility. LPA observed that the non-perishable and perishable food supply was sufficient per regulations, and there were a variety of food types available. The kitchen is an industrial type kitchen, and the dishes and utensils were in sufficient supply. The pots and pans were stored properly, and sharp items were locked at the time of this visit. The floor plans, telephone numbers and personal rights were found posted throughout the facility. The listed Administrator possesses a current administrator’s certification with expiration date of 10/13/2026, for Caroline Senteno. LPA reviewed staff and resident files, along with the facility's staff schedule. The staff files reviewed were current and up to date with clearances and training's. Along with First Aid certifications and TB tests. Resident files were reviewed and possessed required paperwork, along with current TB test. LPA Mixson reviewed the facility's emergency and disaster plan. LPA observed the last fire drill met the department standards and was conducted on 05/26/2026, by a vender who comes to the facility to conduct the fire drills for all shifts. Administrator advised that the staff do sign in. Vendor is Long Term Care (LTC) Safety. LPA Mixson observed the hand washing stations in the facility restrooms, along with PPE equipment and cleaning supplies. Administrator advised that this is for conducting regular cleaning of the facility. LPA reviewed the facility's infection control plan and found required infection control measures. There were no TA deficiencies observed or cited per Title 22, Division 6 of the California Code of Regulations at this time. An exit interview was conducted where a copy of this report was discussed and given to Executive Director, Caroline Senteno.the state’s words, verbatim · CDSS document, Jul 15, 2026

Type of visit: Required - 1 Year

On July 18, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with Business Office Manager, Edith Osio. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 99 Senior Residents, and is currently operating at a capacity of 66 within the scope of the license. (740) LPA Mixson toured the facility and made observations pertaining to the annual visit. LPA inspected the facility inside and outside. There were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. Additionally, there were no bodies of water on the premises. The facility is a two story structure with multiple entry and exits, all exits were observed to be clear and had no safety obstruction at the time of this visit. Physical Plant: The facility phone number is (760) 295-3900 and it is operable. LPA Mixson observed the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations at. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the PUB 475. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit. Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for residents. The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit. Administrator informed LPA there were safety lights for night throughout the facility. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. Care & Supervision/Administration: Adequate staff were present for the supervision of resident in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed Administrator possesses a current administrator’s certification. Records Reviewed and Resident/Staff Files: LPA reviewed staff files and reviewed the facility's staff schedule. The staff files reviewed were current and up-to-date with clearances and training's. Along with First Aid certifications and TB tests. Resident files were reviewed and possessed required paperwork. Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards and was conducted on 06/23/2025, by specialist. Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures. There were no TA deficiencies observed or cited per Title 22, Division 6 of the California Code of Regulations at this time. An exit interview was conducted where a copy of this report was discussed and given to Executive Director, Caroline Sentenothe state’s words, verbatim · CDSS document, Jul 18, 2025

Type of visit: Prelicensing

On July 11, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived for a scheduled visit for the purpose of conducting a Pre-Licensing/CHOW visit. LPA Mixson met with Melody Parks introduced herself, and stated the purpose of the visit. Physical Plant: The facility is two-story building located at 1863 Devon Place Vista CA. 92084. The City of Vista Fire Department was out on 06/04/2024, for a pre-approval visit. Facility has several first aid kits and manuals, the Administrator has received First Aid and CPR training, and the Administrator’s certificate is current. Medications: LPA Mixson observed where medications are locked, and inaccessible to the residents, at the Wellness Center and Nurse's station. The Facility is equipped with lights in the passages and stocked with emergency night lights throughout the facility. The smoke and carbon monoxide detectors were observed and are operable. LPA Mixson observed a sample of the fire extinguishers, and they were charged and in the green. The cleaning supplies were locked and inaccessible, along with the sharp objects and the Administrator informed the LPA there are no firearms on the premises. Living Units: A sample of the living units were observed and were large enough to allow for easy passage between the beds, and other required items of furniture were present currently at the time of this inspection. CONTINUE ON NEXT PAGE Kitchen/Food: The knives were locked in a kitchen drawer, plenty of pots, pans, and other kitchen accessories. The facility has the required seven-day supply of non-perishable food items and the two-day supply of perishable food items. LPA Mixson observed hygiene supplies for residents. There were no pesticides, poisons, or other toxic substances stored in any food storage or preparation area currently at the time of this inspection. (87555). Records: There is confidential storage space for personnel records. (87412). Bathrooms: A sample of the bathrooms were observed and floors were clean and sanitary and free of odors, water and other appliances were operable, water temperature tested within regulations. There were several toilets and sinks for each six persons to include residents, family, and personnel. (87307), and at several showers for each ten persons. (87307). Administration: LPA Mixson observed emergency exiting plans and telephone numbers posted, Personal Rights, Complaint Poster, and other required documents were posted currently at the time of this visit, along with the current Administrators certification. The facility theft and loss program policy are posted, currently at the time of this inspection. (87218). Activities: There are activity supplies and equipment, including access to daily newspapers, current magazines, and a variety of reading materials in the language of choice. There is an outdoor activity area equipped for outdoor use. (87219). Miscellaneous: There are several first aid kits, including sterile dressings, bandages, thermometers, and other items as required by regulations. (87465). There are laundry supplies and equipment, including industrial size machines in good repair, and there is space for clean linen storage and a separate space for soiled linen. (87307). LPA Mixson observed emergency lighting supplies to include flashlights, and extra batteries, along with vehicles used to transport residents are operable and registered as stated by the Administrator. (87303). Dementia Care: There were no bodies of water on the premises, and there are auditory devices in place to monitor exits and completely enclosed outdoor activity space with self-closing latches and gates. (87705). Inside/Outside: All doors, and passageways are clear of obstruction and debris. There were was one fireplace and it was covered with a screen. There was enough clean linen and hygiene items, and there was appropriate lighting in rooms sampled. LPA Mixson observed central air conditioning systems, and it was operable currently. The Administrator dialed the land line phone number (760) 295-3900, and it was operable. Outside/Yards: Had shade and covering for shaded visits, and activities. There were no obstructions observed. The Licensee stated there were no firearms, and/or ammunition on the premises. CAB 8.0 Pre-licensing/CHOW / COMP III was completed on June 18, 2024, applicant/administrator participated in COMP II. An exit interview was conducted, a copy of this report was provided to Administrator, Melody Parks.the state’s words, verbatim · CDSS document, Jul 11, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 99 Census (if any clients in care): 84 COMP II Participants: Jeff Gonzalez Interview Method: Telephone interview On June 18, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Medications/Transportation/Admin backup 3. Pre Licensing inspection readinessthe state’s words, verbatim · CDSS document, Jun 18, 2024