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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604065
Report Date: 12/16/2025
Date Signed: 12/16/2025 11:20:47 AM

Document Has Been Signed on 12/16/2025 11:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:VISTA CARLSBAD SENIOR LIVINGFACILITY NUMBER:
374604065
ADMINISTRATOR/
DIRECTOR:		BENDER, JAMESFACILITY TYPE:
740
ADDRESS:1088 LAGUNA DRIVETELEPHONE:
(760) 434-7116
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY: 214CENSUS: 91DATE:
12/16/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Natalie Carlborg, Executive Director TIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Case Management visit. LPA was met by Natalie Carlborg, Executive Director (ED), and was granted entry into the facility. At the time of the visit, there were 91 residents currently in care.

This visit was initiated due to a self-reported incident involving Resident 1 (R1), which was received by Community Care Licensing (CCL) on August 11, 2025 (08/11/25). The incident involved R1 eloping from the facility unassisted and sustaining a fall that resulted in hospitalization. R1 was later diagnosed with multiple facial fractures and transferred to a trauma center for further evaluation.

During the investigation, interviews were conducted with facility staff and outside sources. Interviews revealed that R1 had a documented history of dementia and Parkinson’s disease and required assistance with medications and eye drops.

Staff acknowledged that R1 had cognitive impairments but in interviews consistently described R1 as “independent.”

Several staff members confirmed that on the day of the incident, R1 was last seen walking out the front door unassisted and that staff did not intervene due to their “independent” status. Interviews with Outside Source 1 (OS1) about R1 reported that R1’s cognitive condition had declined significantly in recent months, including increased confusion and reduced verbal communication. This decline was reported to facility staff and UCSD Neurology - Memory Care Program and should have triggered a reappraisal of R1's condition and care needs. Record review indicated that R1’s cognitive function had been gradually declining, and that R1 had been having increasing difficulties with confusion, recognizing their own handwriting, and decreasing levels of alertness as of their last visit on 7/24/2025.

NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Ramin Hashemi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VISTA CARLSBAD SENIOR LIVING
FACILITY NUMBER: 374604065
VISIT DATE: 12/16/2025
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Additionally, multiple members of staff confirmed that R1 had recently experienced the loss of their pet dog, which had previously provided companionship and routine structure. The loss of the pet represents a significant mental or social trauma as defined in CCR Title 22, Section 87463(b)(1)(D), and should have triggered a reappraisal of R1’s condition and care needs.

Despite these indicators of cognitive decline and social trauma, there was no evidence that the facility updated R1’s appraisal or conducted a reappraisal as required by regulation.

One (1) deficiency was cited per California Code of Regulations, Title 22. (refer to the LIC809-D page). Plans of Correction were jointly developed with the Exectuvei Director.

An exit interview was conducted with Natalie Carlborg, Executive Director to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Ramin Hashemi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2025 11:20 AM - It Cannot Be Edited


Created By: Ramin Hashemi On 12/16/2025 at 10:32 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VISTA CARLSBAD SENIOR LIVING
FACILITY NUMBER: 374604065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2025
Section Cited
CCR
87463(b)(1)(D)

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87463 Reappraisals
(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition... (1) Significant changes in condition, as defined in Section 87101, Definitions, include, (D) A mental or social trauma, such as the loss of a loved one.
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Licensee stated they will continue to provide Elopement Prevention and Reappraisal Training initiated by this event. The training began 08/24/2025. Proof of this plan of correction will be submitted to CCLD Offices no later than 01/16/2026
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Based on observation, interview, and record review, the licensee did not ensure that resident received a reappraisal after significant change in condition, which posed a potential Health, Safety, and Personal rights risks to 1 of 91 persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Ramin Hashemi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2025


LIC809 (FAS) - (06/04)
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