Inspection Reports for The Gardens at Laguna Springs

The visit was a case management visit conducted by the Licensing Program Analyst to review documents related to a former resident, including meal logs, urine and bowel output records, and communications with medical professionals.

No deficiencies were cited during the visit. Staff reported that daily records of meals and urine/bowel output are not routinely kept unless ordered by a doctor or if there is a change in the resident's condition.

The inspection was an unannounced annual required inspection conducted to ensure compliance with Title 22 regulations at the Gardens at Laguna Springs Memory Care facility.

No deficiencies were observed during the visit. The facility was found to be clean, well-maintained, and in compliance with regulations, including proper food supplies, locked medications, and safe emergency exits. Resident and staff files were up to date with required documentation and training.

The inspection was an unannounced complaint investigation triggered by a complaint received on 2024-08-19 regarding pest issues, specifically ants, in a resident's room.

The investigation included observations, records review, and interviews. Although ants were observed in a video submitted as evidence, no pests were found during the inspection visits. The facility has monthly pest control services and increased treatments recently. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff did not ensure that a resident's room was free from pests, specifically ants. The complaint was unsubstantiated after investigation, with no deficiencies cited.

An unannounced 1 Year Annual Inspection Visit was conducted to evaluate the facility's compliance with health and safety regulations.

The inspection found no violations; the facility met required standards for physical plant conditions, food storage, medication security, fire safety equipment, and staff background clearances.

An unannounced complaint investigation visit was conducted following a complaint received on 2023-07-10 regarding multiple allegations about staff practices and resident care at the facility.

The investigation found insufficient evidence to substantiate any of the allegations, including issues related to pull cords accessibility, pest infestation, food access, medication management, supervision of fall-risk residents, inappropriate speech, staff training, and safeguarding residents' belongings. The complaint was determined to be unsubstantiated.

The complaint included nine allegations: staff not ensuring pull cords are accessible, improper pest infestation management, preventing residents from accessing food, mismanagement of medication, inadequate supervision of fall-risk residents, inappropriate speech to residents, insufficient staff training, and failure to safeguard residents' belongings. The investigation concluded all allegations were unsubstantiated.

The visit was a Non-Compliance Conference conducted to follow up with the facility after an initial NCC held on 9/30/2022, addressing six new complaints and four Type A deficiencies cited since the last meeting.

The facility was cited for deficiencies related to Personal Rights of Residents, Administrator Qualifications and Duties, Basic services care and supervision, and Plan of Operation. The focus included oversight of staff, maintaining compliance, and updating policies regarding outside agency staff and admitting residents with behaviors.

Since the last meeting on 9/30/2022, six new complaints have been filed against the facility.

The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2023-07-03 regarding medication administration and food quality, as well as an allegation of uncleared staff.

The investigation found the allegations regarding medication administration and food quality to be unsubstantiated, with evidence showing staff ensured residents took medications as prescribed and food quality met residents' needs. The allegation of uncleared staff was found to be unfounded, with staff background checks verified as cleared.

The complaint investigation was unsubstantiated for medication and food quality allegations, and unfounded for the uncleared staff allegation.

The visit was an unannounced case management follow-up to deficiencies found during a complaint investigation dated 2022-09-19.

The facility was found to have multiple deficiencies including blocking a resident's doorway with a couch, inadequate administrator qualifications, failure to provide adequate supervision resulting in resident injuries, and failure to follow the plan of operation regarding combative and aggressive resident behavior.

The visit followed up on deficiencies identified during a complaint investigation dated 2022-09-19, control number 27-AS-20220919221525.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2022-11-22 alleging that a resident was injured while in care.

The investigation found that the resident sustained a witnessed fall in the bathroom on 2022-10-20 and received medical attention the same day. There was no evidence that blood glucose levels contributed to the fall, and the resident had several chronic health conditions that could have contributed to multiple falls. The complaint was determined to be unsubstantiated due to lack of preponderance of evidence.

Complaint was unsubstantiated; although the allegation may have been valid, there was insufficient evidence to prove the violation occurred.

An unannounced complaint investigation visit was conducted in response to an allegation that staff physically assaulted a resident resulting in injuries.

The investigation found insufficient evidence to support the allegation of staff assault. Interviews and record reviews indicated the resident had multiple falls and bruising, but no evidence staff caused injuries. The complaint was determined to be unsubstantiated.

The complaint alleged staff physically assaulted a resident causing injuries. The investigation was unsubstantiated due to lack of preponderance of evidence.

An unannounced complaint investigation visit was conducted in response to allegations received on 2023-03-09 regarding resident injury due to staff neglect, inadequate staffing, and falsification of incident reports.

The investigation found the allegations of a resident sustaining a severe head injury due to staff neglect and inadequate staffing to be unsubstantiated, and the allegation of staff falsifying incident reports to be unfounded. Interviews and record reviews did not support the complaints.

The complaint included allegations that a resident sustained a severe head injury due to staff neglect, the facility did not have enough staff to meet residents' needs, and staff were falsifying incident reports. The findings were unsubstantiated for the first two allegations and unfounded for the third.

The inspection was an unannounced visit to investigate a complaint received on 2023-02-23 regarding allegations of resident injuries, falls, overmedication, neglect in medication administration, and residents being left soiled.

After conducting interviews and reviewing records, the Licensing Program Analyst determined that the allegations were unfounded with no supporting information discovered. The complaint was deemed false and without reasonable basis.

The complaint included allegations that a resident sustained injuries, suffered falls, was over medicated, was left soiled for a long period, and that staff were not administering medications. The investigation found these allegations to be unfounded.

The Licensing Program Analyst conducted an unannounced quarterly health and safety visit to the facility to ensure compliance with health and safety regulations.

The facility was found to be clean and in sanitary condition with no health and safety concerns. Hot water and indoor temperatures were within required ranges, fire extinguishers were up to date, and staff training and first-aid certifications were current. No deficiencies were observed.

The visit was an unannounced quarterly health and safety case management visit to ensure compliance with Title 22 regulations.

The facility was found to be clean, sanitary, and in compliance with all applicable regulations. No deficiencies were observed during the inspection.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/23/2022 regarding medication dispensing and medication log accuracy at the facility.

The investigation substantiated that staff did not accurately log medication administration records (MARs) for resident R1, with multiple missing staff signatures on MARs for September 2022. The allegation that staff were not dispensing medication as prescribed was previously substantiated and resolved. Other allegations regarding modified diet and glucose testing were found unsubstantiated.

The complaint investigation was substantiated for inaccurate medication logging but unsubstantiated for failure to follow modified diets and glucose testing orders. The substantiated allegation was related to medication logs not being accurately maintained, posing a potential health and safety risk.

An unannounced 1 Year Annual Inspection Visit was conducted to evaluate compliance with regulatory requirements and ensure health and safety standards at the facility.

The facility was found to be in compliance with no violations cited. Observations included COVID-19 mitigation measures, adequate food supplies, locked medication storage, functional fire extinguishers and detectors, and proper staff background checks and training.

An unannounced complaint investigation was conducted in response to an allegation that a resident was being overmedicated with Norco and Morphine.

The investigation found that the resident was on hospice and the facility was following hospice orders for medication administration. The allegation was determined to be unfounded.

The complaint alleged that a resident was being overmedicated with Norco and Morphine. The allegation was found to be unfounded after investigation.

The visit was a Case Management - Legal/Non-compliance conference held to discuss the facility's non-compliance issues and bring the facility back into compliance.

Since licensure in December 2020, the facility has been cited 16 times in the last year for various issues including basic services, medical care, criminal record clearance, administrator qualifications, personal rights, storage space, and resident AWOL. No deficiencies were cited during this visit, but increased monitoring and technical support were planned.

The facility had 8 Type A citations and 8 Type B citations substantiated against it within the last 12 months.

The visit was a Case Management follow-up to an incident report regarding a resident (R1) who was absent without leave (AWOL) from the facility on 7/25/2022.

The facility failed to properly secure the delayed egress door, allowing R1 to exit unsupervised for approximately 9-10 minutes, posing an immediate health and safety risk. The door has since been fixed and staff received in-service training on door security and resident checks.

Unannounced complaint investigation visit conducted due to allegations that staff handled a resident in a rough manner and yelled at a resident.

The investigation found no preponderance of evidence to substantiate the allegations. Interviews and observations indicated that the staff did not handle residents roughly or yell at them, and no deficiencies were cited.

The complaint involved allegations that staff handled a resident roughly and yelled at a resident. The investigation included interviews with multiple staff, a resident, and a family member. The allegations were determined to be unsubstantiated due to lack of evidence.

The visit was conducted to address issues identified during a separate complaint investigation regarding the absence of a diabetic diet menu and lack of a diabetic care plan at the facility.

During the visit, the Licensing Program Analyst observed the Diet and Nutrition Care Manual and reviewed care plans for five diabetic residents. It was found that the facility does not have a specific diabetic diet menu but follows guidelines from the Diet and Nutrition Care Manual and diabetic protocols. No violations or deficiencies were issued during this visit.

The visit was triggered by a complaint investigation concerning the lack of a diabetic diet menu and absence of a diabetic care plan at the facility.

The inspection visit was an unannounced complaint investigation conducted in response to allegations that the facility was not providing residents' medication as prescribed and that facility staff were rude and slammed a door in front of a family member.

The investigation substantiated the allegation that a resident (R1) was given insulin two hours late on 4/29/2022 by staff (S3), violating physician's orders. The allegation regarding rude staff behavior and slamming a door was found to be unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for the medication administration allegation, confirming that resident R1 received insulin two hours late on 4/29/2022. The allegation that staff were rude and slammed a door in front of a family member was unsubstantiated due to insufficient evidence.

An unannounced complaint investigation was conducted following allegations including resident missed medications and staff not following physician's orders.

The investigation substantiated that resident R1 missed his morning insulin dose and was given insulin two hours late on another occasion, posing an immediate health and safety risk. Another allegation of staff falsifying medication records was found unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for allegations that resident missed medications and staff did not follow physician's orders. The allegation that staff falsified medication records was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility did not follow a resident's care plan and had insufficient staffing to meet residents' needs.

The investigation found that care was not completed on some days for resident 0, medications were not administered as required, and the facility lacked adequate staff to meet residents' needs during activities and meal times. Residents were observed unsupervised or not properly assisted, posing potential health and safety risks. The allegations were substantiated.

The complaint was substantiated based on evidence including review of resident care records, medication administration records, observations of insufficient staffing during activities and meals, and interviews. The preponderance of evidence supported the allegations.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-03-30 regarding resident behavior and safety concerns at the facility.

The investigation substantiated that resident 1 (R1) was physically aggressive towards other residents, posing a health and safety risk. The allegation of sexual misconduct by R1 was unsubstantiated due to lack of evidence. The allegation that R1 eloped from the facility was found to be unfounded as R1 only accessed a locked gated patio on facility premises and was redirected back inside.

The complaint investigation included three allegations: 1) Resident physically abusive to other residents (substantiated), 2) Resident being sexually inappropriate towards female residents (unsubstantiated), and 3) Resident eloped from facility (unfounded).

The visit was conducted as a case management visit in response to learned deficiencies during a complaint investigation concerning Resident 1's significant physical, medical, and mental changes and the facility's failure to complete timely reassessments.

The facility failed to conduct reassessments after Resident 1's significant health changes, including suicidal ideations, multiple falls, and elopement behaviors, which resulted in a serious injury. Additionally, cleaning carts were left unlocked, making cleaning supplies accessible to residents, posing an immediate health and safety risk.

The visit was triggered by a complaint investigation regarding Resident 1's care, including failure to reassess after significant health changes, suicidal ideations, falls, and elopement behaviors. The complaint was substantiated with findings of deficiencies and an immediate $500 civil penalty was assessed.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2022-01-03 regarding water leaks in a resident's room, safeguarding of residents' personal belongings, and adequacy of laundry services.

The investigation substantiated that the facility failed to maintain a resident's AC unit in good repair, resulting in water leakage and unsanitary conditions, and failed to safeguard residents' clothing and provide adequate laundry services. Other allegations related to preventing inappropriate behaviors, notification of injuries, and room cleanliness were found unsubstantiated.

The complaint investigation was triggered by allegations including a water leak in a resident's room, failure to safeguard residents' personal belongings, inadequate laundry service, failure to prevent inappropriate behaviors, a resident sustaining a rash, failure to notify authorized representatives of injury, and improper cleaning of resident rooms. The investigation substantiated the first three allegations but found insufficient evidence to substantiate the others.

The inspection was an unannounced complaint investigation triggered by allegations including unlawful eviction and staff lacking required training.

The investigation substantiated that a resident was unlawfully evicted without proper documentation and that the facility failed to comply with dementia training requirements for several employees.

The complaint was substantiated based on evidence that the eviction was unlawful and that staff did not meet dementia training requirements.

An unannounced case management visit was conducted to review compliance with licensing requirements, including staff fingerprint clearance and administrator certification.

The facility was found to have staff who were not fingerprint cleared as required and lacked a certified administrator, posing immediate health, safety, and personal rights risks to residents.

The visit was an unannounced annual inspection conducted to ensure compliance with Title 22 regulations and to evaluate the facility's physical plant and infection control measures.

The facility was found to be clean, in good repair, and compliant with regulations. No deficiencies were cited during the visit. Infection control measures, including a COVID-19 mitigation plan, were in place and approved.

Pre-licensing visit conducted via Zoom to evaluate the facility prior to licensing.

The facility was found to be in compliance with no deficiencies observed during the pre-licensing visit. The facility has appropriate secured medication rooms, fire extinguishers, and suitable living and activity areas.

Initial licensing evaluation conducted via telephone call to assess applicant and administrator understanding of Title 22 regulations and facility operation requirements.

Applicant and administrator successfully completed Component II, demonstrating understanding of facility operation, staff qualifications, program policies, and compliance requirements. No clients were in care at the time of the evaluation.