374604545-3-30-2025-18-AS-RORN-DFJTAK-20250408143340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604545
Report Date: 03/30/2025
Date Signed: 03/30/2025 10:21:57 PM

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
10/06/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20231006100625

FACILITY NAME:	GARDENS AT ESCONDIDO		FACILITY NUMBER:	374604545
ADMINISTRATOR:	MCBRIDE, FERLINA		FACILITY TYPE:	740
ADDRESS:	1342 NORTH ESCONDIDO BLVD		TELEPHONE:	(760) 480-8155
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	101	CENSUS: 69	DATE:	03/30/2025
		UNANNOUNCED	TIME BEGAN:	08:03 AM
MET WITH:	Philip Green		TIME COMPLETED:	03:04 PM

ALLEGATION(S):

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Staff yells at residents.

INVESTIGATION FINDINGS:

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On March 30, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent visit to gather information regarding the above allegation. LPA met with Philip Green, the Food Services Director, and explained the purpose of the visit. LPA contacted Monica Flores, Executive Director, and informed Flores of the intention of the visit.

The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #7 (S1-S7) and resident members #1 to #9 (R1-R9). List of documents reviewed/obtained Resident Roster (dated 09/28/23 & 03/29/25), Staff Roster (dated 10/11/23 & 03/29/25), (R1)'s Physicians Report LIC 602 (dated 06/01/22 and 11/02/22), Residence and Care Agreement (dated 06/06/22), Resident Assessment (dated 06/03/22), Identification and Emergency Information LIC 601 (dated 06/02/22), and other pertinent documents associated with this complaint.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2025

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-20231006100625

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: GARDENS AT ESCONDIDO	FACILITY NUMBER: 374604545
	VISIT DATE: 03/30/2025

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff yells at residents.

The complaint states that the facility staff yelled at Resident #1 (R1). On October 5, 2023, during a meeting with residents about the facility's updated policies, Staff #1 (S1) reprimanded (R1) after (R1) asked a few questions regarding the new mileage radius of the facility van. Following the meeting, (S1) approached (R1) and criticized (R1) for asking questions in front of other residents in the meeting. (R1) felt humiliated as a result of this confrontation.

On October 11, 2023, between 10:00 AM and 11:30 AM, the Department interviewed a staff member identified as Staff #1. (S1) denied having yelled at Resident #1 (R1) and stated that this accusation was false. (S1) explained after the Meet and Greet meeting held on October 5, 2023, (R1) approached (S1) while leaving the meeting. (R1) stated to (S1), “Why are you being so mean to me?” (S1) reported stating to (R1) that (S1) has not been mean to (R1) and that the new transportation policy would only affect new residents that are placed at the facility after the facility’s attorneys revise the admission agreement. (S1) firmly denied raising (S1)'s voice at (R1).

On October 11, 2023, between 10:00 AM and 11:30 AM, the Department interviewed a staff member referred to as Staff #2 (S2). During the interview, S2 recounted an incident from the Meet and Greet meeting held on October 5, 2023, where (R1) asked several questions and who advocated for other residents facing cognitive impairment challenges. Due to (R1)'s persistent questioning during the meeting, Staff #1 (S1) appeared to be "annoyed" and dismissed (R1)'s inquiries, stating, "No, not right now, give me a second." (R1) continued addressing sensitive issues related to facility turnover, visibly upset (S1). (S2) reported that (R1) felt upset over the negative interaction after the meeting and apologized for the encounter with (S1). Furthermore, (S2) mentioned, according to (R1), that (S1) reprimanded (R1) and yelled, "Don't you ever speak to me like that again!" in front of the residents. This confrontation left (R1) feeling humiliated.

On March 29, 2025, between 11:50 AM and 12:30 AM, the Department interviewed staff members identified as Staff #3 through Staff #5. Three (3) of the three (3) staff members were unable to recount any incident between Resident #1(R1) and Staff #1(S1) on October 5, 2023. Not all staff members were able to confirm this accusation. Both (S3) and (S4) noted that (S1) and (R1) displayed inconsistent behavior but did not witness the incident themselves or hear from others if it had occurred.

(Evaluation Report continue LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2025

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20231006100625

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: GARDENS AT ESCONDIDO	FACILITY NUMBER: 374604545
	VISIT DATE: 03/30/2025

NARRATIVE

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On March 29, 2025, between 09:25 AM and 11:45 AM, the Department interviewed resident members identified as Resident #2 through Resident #8 (R2-R8). Seven (7) out of the seven (7) resident members confirmed are unable to validate this accusation. (R2-R8) commended all facility staff, noting that their interactions with Staff #1 (S1) were cordial and professional. They also stated that they had never witnessed inappropriate behavior from (S1).

The Department attempted to interview Resident #1 (R1) several times by telephone, but these attempts were unsuccessful because the contact number was no longer valid. Additionally, (R1) is no longer a resident at the facility and did not provide a forwarding contact address.

The Department reviewed Resident #1 (R1)’s Residence and Care Agreement California (dated June 06, 2022). It revealed outlined on page 26 subsection (I), title “Personal Right,” indicated in part, "Consistent with California Law, you shall have the rights set forth in the Statement of Residents’ Personal Rights. A review (R1)’s Physician's Report LIC 602 (dated 06/01/22 and 11/02/22) revealed (R1) had no mental health challenges. Further review of (R1)’s prescribed medication (dated 11/02/22) revealed that all nine medications had side effects affecting psychological condition, including anxiety, headaches, dizziness, confusion, and trouble concentrating (ref: National Institutes of Health - NIH). An additional review of staff training records verified staff had completed Workplace Sensitivity Training Courses, including Resident Rights, Elder Abuse, Sexual Harassment Prevention, Cultural Competency, Standard Precautions, and Customer Service.

During the visit on March 29 and 30, 2025, the Department identified that the facility promotes the rights of its residents. To improve the environment, posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. This helps ensure that residents are well-informed about their rights, contributing to their well-being.

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is determined Unsubstantiated.

An exit interview was conducted with Philip Green, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2025

LIC9099 (FAS) - (06/04)

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