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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604516
Report Date: 06/19/2025
Date Signed: 06/19/2025 10:15:10 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
09/04/2024 and conducted by Evaluator Rebecca A Borunda
COMPLAINT CONTROL NUMBER: 08-AS-20240904091815
FACILITY NAME:WEAVER'S LILAC VILLAFACILITY NUMBER:
374604516
ADMINISTRATOR:LISA ANDERSON-HINESFACILITY TYPE:
740
ADDRESS:49 AVENIDA DESCANSOTELEPHONE:
(760) 696-3101
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 6DATE:
06/19/2025
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator Juliane CruzTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Questionable Death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Administrator Juliane Cruz.

The Department’s investigation consisted of interviews with residents and staff, review of facility records, and a tour of the facility. It was alleged that a medication error resulted in Resident 1’s (R1) death. Review of R1’s assessment records dated June 2022 and interviews with staff revealed that R1 had a diagnosis of esophageal cancer, had a tracheostomy, was not confused or disoriented, but was able to communicate needs and follow instructions. Review of R1’s medical records from April 2023 and assessment records dated June 2022 revealed that R1 was receiving hospice services for esophageal cancer and was discharged from hospice services in December 2022.

Continued on LIC9099-C page...
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
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 2
Control Number 08-AS-20240904091815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WEAVER'S LILAC VILLA
FACILITY NUMBER: 374604516
VISIT DATE: 06/19/2025
NARRATIVE
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Review of R1’s medication list for May 2023 revealed that R1 had been prescribed numerous medications, including one routine pain medication and five as needed (PRN) medications for pain relief, one of which was the pain medication hydromorphon 2mg. Review of R1’s medication list between November 2022 and May 2023 revealed that R1 was prescribed hydromorphon 2mg as needed every 2 hours. Interviews with staff revealed that the facility did not keep a Medication Administration Record (MAR) for routine medications, but did maintain a MAR for PRN medications, including R1’s hydromorphon. Interviews with staff and review of R1’s death certificate revealed that R1 had a surgical operation to correct a complication from R1’s tracheostomy on 5/11/2023. Review of R1’s MAR for hydromorphon revealed that following R1’s surgery on 5/11/2023, R1 was given 2mg hydromorphon on 5/13/2023 at 11:30am and 2:00pm. R1 received additional doses of hydromorphon at 5:00pm, 8:00pm and 11:00pm, however, those doses had a handwritten note next to each dose that the dose given was 3mg. On the following page of R1’s MAR, another handwritten note stated that the doctor changed the dose and frequency to 3mg every 3 hours. The MAR revealed that R1 received 3mg of hydromorphon approximately 3 hours apart. Interviews with staff revealed that R1 was very aware of R1’s medication schedule and routine, and would frequently ask for their prescribed medications, including pain medications more often than the medication was allowed by the doctor’s order. Review of R1’s death certificate revealed that R1’s cause of death was listed as tongue cancer, and did not list any conditions related to medications contributing to R1’s death.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Administrator Juliane Cruz, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
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