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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604198
Report Date: 09/30/2026
Date Signed: 09/30/2026 09:53:33 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 18-AS-20220927084345
FACILITY NAME:VISTA GARDENSFACILITY NUMBER:
374604198
ADMINISTRATOR:JAMES MCALEERFACILITY TYPE:
740
ADDRESS:1863 DEVON PLACETELEPHONE:
(760) 295-3900
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:0CENSUS: DATE:
09/30/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:TIME COMPLETED:
10:01 AM
ALLEGATION(S):
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Resident sustained a pressure injury while in care due to negligence.
Facility was not aware of change in resident's medical condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jeffries issued final findings for this investigation via US mail, certified mail, and email to the last known mailing address. The facility closed effective 07/29/2024.

On 09/27/2022, 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) developed a pressure injury while in care at the facility due to staff neglect and lack of care and supervision. The complaint also included allegations that the facility was not aware of a change in a resident’s medical condition and facility did not meet resident’s toileting needs.

On 09/28/2022, from 9:20am to 10:45am, Licensing Program Analyst (LPA) Mixson conducted an unannounced initial complaint investigation visit to the facility. LPA Mixson met with Office Manager Karina Tellez and explained the reason for the visit.
CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 18-AS-20220927084345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VISTA GARDENS
FACILITY NUMBER: 374604198
VISIT DATE: 09/30/2026
NARRATIVE
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During the visit, the LPA collected relevant documentation for Resident #1 (R1). Additionally, the Department conducted interviews on 11/29/2022 with Interim Administrator Rachel McIntyre; on 12/30/2022 with Administrator Hilda Paz; and on 09/28/2022 with Family Member #1 (F1). The Department also reviewed medical records from Scripps Health and facility documents related to the investigation, including physician’s report, preplacement appraisal, and shower/care logs. Per Administrator Hilda Paz, R1’s Preplacement appraisal could not be located.
As to the allegations, “Resident sustained a pressure injury while in care due to negligence” and “Facility was not aware of change in resident's medical condition.” It was alleged R1 sustained a stage 3 pressure injury due to neglect, and staff were not aware of the injury.
R1 moved into the facility on 08/04/2022. R1’s physician’s report dated 08/02/2022 states R1 was diagnosed with Major Neurocognitive Disorder with Behavior Disturbance, unspecified depression, and unspecified psychosis. The report states R1 did not have a history of skin breakdown, was able to communicate their needs, and required assistance with all self care, except eating, due to the dementia.
F1 stated during a visit on 09/25/2022, they observed R1’s right lower leg swollen, red, hot, and weeping. F1 had previously seen R1 on 09/09/2022 and R1 did not have the injury. F1 stated they asked staff about it, and they admitted they were unaware of the injury. F1 took R1 to Urgent Care, who then recommended R1 go to the Emergency Room. R1 was diagnosed with a stage 3 infected decubitus ulcer (pressure injury) with cellulitis and a Urinary Tract infection (UTI). F1 stated R1 moved into the facility walking with a walker and with skin intact. F1 stated after moving in, staff had R1 sit on their walker and pushed R1 around instead of letting R1 walk. F1 stated this was because R1 walked slowly and staff were inpatient, and believes as a result R1 was sitting most of the day. F1 stated after R1 moved in, staff asked about a wheelchair, which F1 declined since R1 could walk.
Interim Administrator McIntyre stated she had become the Interim Administrator on 04/07/2022, and prior to that had been the Health and Wellness Director of the facility for five years. From 04/07/2022 to 10/06/2022, McIntyre was covering both positions in the facility. Interim Administrator stated R1 was assessed by the marketing director prior to admission and a physician’s report was obtained, where no major issues were identified other than dementia with behavior issues. Interim Administrator stated R1 was ambulatory, typically with a walker. Interim Administrator stated R1 needed mostly standby, one-person assist with prompting, and was identified as a fall risk due to their cognitive ability; however, Interim Administrator was not aware of R1 falling.
CONTINUED on LIC9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20220927084345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VISTA GARDENS
FACILITY NUMBER: 374604198
VISIT DATE: 09/30/2026
NARRATIVE
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 Interim Administrator stated F1 discovered a wound on the inside of R1’s ankle, and stated the wound was “unstageable.” Interim Administrator stated they were aware R1 had refused to get up for a few days, and stated caregivers did not observe the wound since R1 had socks on. Interim Administrator stated R1 took showers during the day, and the day shift staff should have observed the wound from the onset. Interim Administrator completed an Incident Report (IR) on 09/25/2022 when the wound was discovered. Interim Administrator McIntyre stated after R1 moved out, they checked the other residents but did not find any skin issues, and provided caregivers training on skin integrity.
R1’s Body Check form completed upon admission on 08/04/2022 indicates no pressure injuries on R1’s body, and only noted an old bruise on the left shoulder. Interim Administrator stated other body checks would be conducted during showers. Interim Administrator stated caregivers would complete a shower log and identify issues that would be reported to the Med Tech or nurse. Interim Administrator noted that R1 was refusing to get out of bed and take showers, and stated that would also triggered a body check. The Resident Check-Off List is used by caregivers to record the care provided to the residents. The lists for 09/14/2022 to 09/23/2022 do not notate any skin abnormalities for R1. The symbols used on the chart seem to vary by the staff completing the form with no consistency. However, the chart shows a checkmark indicating R1 received a shower on 09/23/2022, 09/21/2022, 09/19/2022, 09/16/2022, and 09/14/2022, and received assistance with Personal Hygiene (oral care, hair, face/shave, nail care, dressing) each day from 09/14/2022 to 09/23/2022. There was no documentation of refusals to shower or participate in care.
Medical records confirm on 09/25/2022, R1 was seen at the Scripps Coastal Medical Center Jefferson Urgent Care. The visit diagnosis is listed as “Decubitus ulcer, Stage 3 with infection,” and was described as an ulceration of the right medial malleolus about 2cm in diameter. R1 was sent to the emergency room at Scripps Memorial Hospital Encinitas. Emergency Department records confirm the stage 3 pressure injury as well as cellulitis. Photographs taken of R1 appear in the health records showing the right ankle is swollen, red, and there is a notable wound on R1’s inner ankle.
Based on all interviews conducted and documents reviewed, the allegations are substantiated at this time.
A $500 immediate civil penalty is assessed today. This report notified the licensee that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).
Copy of report and appeal rights provided to licensee via mail, certified mail and email.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 18-AS-20220927084345

FACILITY NAME:VISTA GARDENSFACILITY NUMBER:
374604198
ADMINISTRATOR:JAMES MCALEERFACILITY TYPE:
740
ADDRESS:1863 DEVON PLACETELEPHONE:
(760) 295-3900
CITY:VISTASTATE:CAZIP CODE:
92084
CAPACITY:0CENSUS: DATE:
09/30/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:TIME COMPLETED:
10:01 AM
ALLEGATION(S):
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Facility did not meet resident's toileting needs.
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA) Jeffries issued final findings for this investigation via US mail, certified mail, and email to the last known mailing address. The facility closed effective 07/29/2024.
On 09/27/2022, 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) developed a pressure injury while in care at the facility due to staff neglect and lack of care and supervision. The complaint also included allegations that the facility was not aware of a change in a resident’s medical condition and facility did not meet resident’s toileting needs.
On 09/28/2022, from 9:20am to 10:45am, Licensing Program Analyst (LPA) Mixson conducted an unannounced initial complaint investigation visit to the facility. LPA Mixson met with Office Manager Karina Tellez and explained the reason for the visit. During the visit, the LPA collected relevant documentation for Resident #1 (R1).
CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20220927084345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VISTA GARDENS
FACILITY NUMBER: 374604198
VISIT DATE: 09/30/2026
NARRATIVE
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Additionally, the Department conducted interviews on 11/29/2022 with Interim Administrator Rachel McIntyre; on 12/30/2022 with Administrator Hilda Paz; and on 09/28/2022 with Family Member #1 (F1). The Department also reviewed medical records from Scripps Health and facility documents related to the investigation, including physician’s report, preplacement appraisal, and shower/care logs. Per Administrator Hilda Paz, R1’s Preplacement appraisal could not be located.
As to the allegation, “Facility did not meet resident's toileting needs.” It was alleged the facility did not meet R1’s toileting needs.
F1 stated R1 was continent, but the facility used briefs for R1. F1 stated on one visit, R1’s room smelled strongly of urine. F1 stated R1 had urinated on a new chair they had brought into the facility, likely due to sitting too long and not being toileted. F1 stated at the time, R1 was recovering from a UTI and was on antibiotics.
Additional records and interviews were unable to be obtained due to the facility closure. LPA observed in the Scripps Memorial Hospital Encinitas Emergency Department notes that R1 was diagnosed with a bladder infection/Urinary Tract Infection on 09/25/2022 and was prescribed antibiotics. Although there was evidence that due to staff neglect, R1 sustained a pressure injury, there was insufficient evidence to definitively prove the staff did not meet R1’s toileting needs.
Based on all interviews conducted and documents reviewed, 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, copy of report issued via mail and email.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20220927084345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA GARDENS
FACILITY NUMBER: 374604198
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2026
Section Cited
CCR
87468(a)((4)
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87468.2(a)(4) Personal Rights
…residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet Based on interviews and record
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Facility closed 07/29/2024.
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their needs. This requirement was not met as evidenced by: review, the licensee did not comply with the section cited when R1 developed pressure injuries in care, which posed an immediate health and safety risk to residents in care.
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Type A
10/01/2026
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes…the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person…This requiorment
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Facility closed 07/29/2024.
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 was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited when they did not observe R1’s pressure injuries or seek proper treatment or notification, which posed an
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immediate health and safety risk to residents in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6