374604065-5-19-2025-08-AS-SJAB-DGUU3Y-20250520151418

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604065
Report Date: 05/19/2025
Date Signed: 05/19/2025 04:07:34 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2025 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20250514140214

FACILITY NAME:	LAGUNA ESTATES SENIOR LIVING		FACILITY NUMBER:	374604065
ADMINISTRATOR:	WESLEY LAVENDER		FACILITY TYPE:	740
ADDRESS:	1088 LAGUNA DRIVE		TELEPHONE:	(760) 434-7116
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	214	CENSUS: 93	DATE:	05/19/2025
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Executive Director Kimberly "Kim" Bonn and Health Services Director Katie Ferguson		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Licensee did not allow resident to keep their bed rails on their bed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Receptionist Lyn Anzalone. LPA then met and debriefed with Executive Director Kimberly "Kim" Bonn and Health Services Director Katie Ferguson.

The Complainant alleged that Licensee did not allow Resident #1 (R1) to keep their bed rails on their bed. [See LIC811 Confidential Names List for a description of R1.] CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of R1, pertinent staff, and pertinent outside sources. The Department also reviewed relevant care and administrative records.

[CONTINUED ON LIC 9099-C, 1 of 2]

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025

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 4

Control Number 08-AS-20250514140214

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LAGUNA ESTATES SENIOR LIVING	FACILITY NUMBER: 374604065
	VISIT DATE: 05/19/2025

NARRATIVE

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[CONTINUED FROM LIC 9099]

Per R1’s Face Sheet, they had lived at the facility since February 2024. Per R1’s LIC602 Physician’s Report, corroborated by their Preplacement Appraisal and latest Individual Service Plan: R1’s primary diagnosis and reason for being at the facility was hemiplegia and hemiparesis following a stroke. R1 experienced residual left sided weakness and had history of knee replacement. R1 required hands-on staff assistance with transferring in/out of bed, and with rotating/repositioning in bed, among other activities of daily living.

During his 05/19/2025 visit, LPA observed: R1 had a hospital bed in their bedroom, but the pair of half-length bed rails were not affixed to R1’s bed. The rails were instead set aside on the floor.

Staff interviews showed: R1 rented their hospital bed (which came with the rails) from a third-party durable medical equipment (DME) company. (Therefore, both the bed and the rails in question were R1’s personal property, and not Licensee’s property.) About one month earlier, facility manager Staff #1 removed R1’s bed rails from R1’s bed, because the rails conflicted with Licensee’s internal facility/company policy.

LPA subsequently obtained a copy of Licensee’s internal facility/company policy, which stated in part: “The use of bed rails is discouraged [at the facility]. Half bed rails are only utilized to assist in mobility and not as a restraint and are only used with specific physician’s order mandating the use and will require the permission of the Regional Director of Health Services.”

California Code of Regulations, Title 22, Section 87608 titled “Postural Supports,” states in part: “(a)(5)(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.” Regulation does not require a physician’s order for half-length bed rails. CCLD also reviewed the Admissions Agreement contract between R1 and Licensee, finding no mention of the facility’s stance/policy on bed rails.

[CONTINUED ON LIC 9099-C, 2 of 2]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20250514140214

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LAGUNA ESTATES SENIOR LIVING	FACILITY NUMBER: 374604065
	VISIT DATE: 05/19/2025

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 2]

Interviews further showed: For most of R1’s residency at the facility (over a year), R1 had bed rails on their hospital bed, without issue. R1 and their responsible person (RP) both affirmed to CCLD their strong preference for R1 to have the half-rails affixed to their bed, because they help R1 feel more secure and are a potential grab-point for R1’s hand during assisted transfer/rotation maneuvers. Neither person considered the half-rails to be a restraint. Both persons were unaware of Licensee’s reasoning for removal of the bed rails. R1 subsequently communicated their desire for their rails to be reattached to facility direct care staff (as confirmed by both R1 and direct care staff). Licensee therefore had constructive knowledge to timely remedy.

Based on records and interviews, a preponderance of evidence exists to show Licensee did not allow Resident #1 (R1) to keep their bed rails on their own bed. The allegation is therefore Substantiated, and one (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Executive Director Kim Bonn and Health Services Director Katie Ferguson, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20250514140214

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LAGUNA ESTATES SENIOR LIVING	FACILITY NUMBER: 374604065
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/30/2025 Section Cited CCR 87468.2(a)(14)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (14) To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility…” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Licensee agreed arrange for R1’s half-length bed rails to be reattached to their hospital bed as soon as possible, and to E-mail photos of such to LPA, by the POC due date. Doing so will satisfy regulation, as it is written. [This does not preclude Licensee from subsequently coordinating with R1’s physician and/or responsible person (RP) to do any of the following, if it pleases Licensee: a) pursing a doctor’s order for R1’s half-rails; b) conferring with Licensee’s Regional Director of Health Services; and/or, c) inquiring with R1 and RP to see if they would prefer a Halo Rail over a half-length bed rail.]
	8 9 10 11 12 13 14	Based on records review and interviews, Licensee did not reasonably accommodate the individual need/preference of 1 of 93 residents (R1) regarding their life at the facility, when the specific accommodation that R1 requested was reasonable with respect to safety. This posed a potential personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025

LIC9099 (FAS) - (06/04)

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