371881719-4-22-2026-18-AS-JDHS-DTMM3G-20260430091505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 371881719
Report Date: 04/22/2026
Date Signed: 04/22/2026 04:13:08 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/14/2025 and conducted by Evaluator Venus Mixson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20251014120447

FACILITY NAME:	VISTA SENIOR LIVING, LLC		FACILITY NUMBER:	371881719
ADMINISTRATOR:	KAKANI, SHRIKANT		FACILITY TYPE:	740
ADDRESS:	222 WASHIGTON ST		TELEPHONE:	(619) 791-5495
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	15	CENSUS: 15	DATE:	04/22/2026
		UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	FACILITY MANAGER, ELENA LEON		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff did not ensure resident's pressure injury was covered with a dressing.

INVESTIGATION FINDINGS:

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On April 22, 2026, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced at the facility and met with the Facility Manager, Elena Leon. 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 October 14, 2025, Community Care Licensing received a complaint alleging that Staff did not ensure resident's pressure injury was covered with dressing. It was reported that on 10/13/25, the Patient was laying on their side with exposed coccyx wound. Resident #1 (R1), and that there was a pressure mattress that was being used incorrectly since R1 was laying on blanket and thick pad. When interviewed the Administrator denied the allegation. The Administrator stated R1 had just gotten out of the shower and was drying off, and at about the same time that R1 was on the bed drying off, the Home Health nurse arrived. Administrator advised that the home health nurse was overreacting. Information obtained from Interviews with staff members indicated that the incident took place in R1’s person bedroom, and that R1’s bathroom is also in their bedroom.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20251014120447

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA SENIOR LIVING, LLC	FACILITY NUMBER: 371881719
	VISIT DATE: 04/22/2026

NARRATIVE

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Additional information obtained from staff members indicated that there were no concerns brought to their attention regarding the use of the pressure mattress.
When interviewed, R1 stated there were no concerns since their arrival to the facility and that they have only been receiving services from Home Health for a few weeks. R1 advised that they had just recently arrived at the facility a few months ago, and that this was the first time the nurse had ever come to the facility to dress or change the bandages. There were no stated concerns or challenges with how the facility staff attended to meeting their daily needs. Information obtained from interviews with additional residents indicated there were no concerns or challenges with how the facility staff attend to their daily needs. LPA made several attempts to contact and interview additional relevant Witness to no avail. LPAs review of the records, including a sampling of the residents files, verified there were no other residents receiving care from home health for pressure injuries at the time of this investigation.

Based on information obtained from interviews, record review and observations, the evidence received pertaining to the allegation

Staff did not ensure resident's pressure injury was covered with dressing, 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 demonstrate the alleged violation did or did not occur.

An exit interview was conducted. A copy of this report was discussed and given to the Facility Manager, Elena Leon.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

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