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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804037
Report Date: 09/24/2024
Date Signed: 09/24/2024 01:19:08 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20240911154125
FACILITY NAME:VISTA HOMEFACILITY NUMBER:
486804037
ADMINISTRATOR:MEEHLEIB, MICHAEL CLARKFACILITY TYPE:
740
ADDRESS:2712 VISTA LINDATELEPHONE:
(650) 483-7269
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:4CENSUS: 4DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Daryl Convento, LVN/StaffTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Faciltiy failed to seek timely medical attention for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint findings regarding the allegation listed above and was welcomed by staff/LVN Daryl Convento who contacted by phone Licensee and authorized staff to sign for today’s visit.

Facility failed to seek timely medical attention for resident – Reporting party alleges client (C1) had a seizure and facility staff neglected to take C1 to emergency room for check up and treatment. Documents obtained revealed C1 moved to facility 10/14/2022. Interview with staff (S1) informed C1 has a history of seizures although has not had one since 12/2022. One morning during the middle of the week at the end of August 2024. C1 was getting ready for the day and came into the kitchen and informed S1 they believed they may have fallen down and possibly had a seizure. S1 assessed C1 who was walking normal and not complaining of any pain or show any signs of having a seizure. C1 proceeded to, hurry to get ready to leave for the day as usual and was gone in approximately 30 minutes.
Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
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 21-AS-20240911154125
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VISTA HOME
FACILITY NUMBER: 486804037
VISIT DATE: 09/24/2024
NARRATIVE
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Continue from LIC9099-

During LPA visit, while interviewing Licensee, C1 interjected stating that they fell in their room recently while getting ready for the day but didn’t get hurt and S1 assessed them. Previous Incident reports obtained revealed the facility had submitted 2 reports for C1 when they first moved in for seizures and went to the ER for treatment. Although reporting party alleges facility failed to seek timely medical attention for resident, investigation revealed client has not had a seizure in almost 2 years and went to their day program immediately after incident. Therefore, the allegation is Unsubstantiated.

Although the allegation above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2