Gardens at Escondido.

On 02/06/2026, Licensing Program Analyst (LPA), Jacqueline Shaw-Ross arrived at the facility unannounced to conduct a required annual inspection and met with Executive Director, Monica Flores. The facility file review was conducted at the Regional Office and additional forms were requested and reviewed on site. The facility is licensed for 101 elderly residents; ages 60 and above; all of whom may be non-ambulatory, ten (10) of which may be bedridden. A hospice waiver is approved for 18 residents; and approved for delayed egress. LPA Shaw-Ross toured the facility, and inspected the facility inside and outside. There were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. The facility consist of three levels for assisted living and one level for memory care. Physical Plant: The facility phone number is (760) 480-8155 and is operable. LPA Shaw-Ross observed a sample the residents’ living units, and each was equipped with required furniture as per Title 22. LPA Shaw-Ross inspected a sample of the facility restrooms on the first floor as well as bathrooms in residents living units, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately, and there was liquid soap and paper towels currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. LPA Shaw-Ross reviewed the facility's fire extinguisher logs, emergency fire drill log, and all are being serviced regularly. First aid kit(s) were complete and readily accessible. LPA Shaw-Ross observed required postings such as "If you See Something, Say Something" the "Personal Rights," along with the Ombudsman in common areas throughout the facility. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There is designated storage space for residents and staff files, that are inaccessible to residents in care currently at the time of this visit. Medications : Were locked and inaccessible to residents in care, and there is a sufficient supply of medication for each resident. LPA reviewed a sample of resident medications to ensure medications are dispensed accordingly. No medication errors were observed at the time of visit. The facility cooling system and other appliances were operable currently at the time of this visit. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. Care & Supervision : Facility has sufficient staff on site at the time of this visit. Receptionist at the front desk, maintenance team, and house keeping teams were observed on each floor. Nurses and other care staff were in sufficient numbers for this facility type. Records Review: LPA Shaw-Ross reviewed a sample of seven (7) resident and six (6) staff files, conducted resident and staff interviews,and reviewed previous Community Care Licensing forms. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted, and a copy of this report was discussed and provided to Executive Director, Monica Flores.

A review of the relevant medical records related to R1’s hospitalization were reviewed. The medical records indicated R1 was not diagnosed with a burn. R1 was diagnosed with injuries related to R1’s health conditions. The investigation did not provide sufficient evidence that staff neglect caused the injuries R1 was diagnosed with. The investigation further revealed staff obtained timely medical attention for R1’s observed injuries. Therefore, based on interviews and records review the allegation is unfounded. A finding that the complaint is unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted where a copy of this report was reviewed and provided to Monica Flores, Executive Director.

(Continued from LIC9099 p.1) Outside sources informed that R1 no longer had the mental capacity to sign an updated Power of Attorney document that would have restricted communication. R1 was interviewed during the facility visit. R1 informed that they enjoyed living at the facility and that they were able to communicate with their family and friends freely. R1 did not express any concerns about living at the facility. No records were found to show that R1 was restricted from communicating with family, friends, practitioners, or any other outside person. Regarding the allegation, "Licensee did not allow resident to leave facility", staff interviews revealed that R1 was not able to leave the facility unassisted due to cognition, however R1 was able to leave with an escort, which had been done many times. Staff informed that a family member typically arranged for R1 to be picked up from the facility and brought back. During interview R1 informed that they remained at the facility most of the time, but their family came to visit them. R1 did not express concern regarding the facility allowing them to leave the facility. An outside source (OS1) familiar with R1 informed that R1 suffered from diminished capacity but was able to leave the facility with someone. OS1 informed that the facility had not prevented R1 from leaving the facility with an escort. A second outside source, OS2, corroborated staff statements that R1 was not allowed to leave the facility by themselves due to cognition. Review of facility and outside source records showed inconsistent determinations regarding R1's mental capacity, however, R1's Physician's Report specifically indicated that R1 was not allowed to leave the facility unassisted due to cognition. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Monica Flores, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Executive Director Monica Flores, to discuss the purpose of the visit. Today's visit is in response to the facility's self report of a fire in a resident's room. The investigation revealed that the personal lamp owned by the resident involved tipped over and malfunctioned, starting the fire. The resident attempted to put the fire out with a blanket. Staff responded immediately to the fire alarm and extinguished the fire with a fire extinguisher. Fire department and paramedics responded to the scene. Residents were assessed and no injuries were identified. No resident was transported to the hospital during the event. The investigation revealed that the staff members involved assisted the residents to safety. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Monica Flores, Executive Director, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.

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) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

(Continued from LIC9099) Due to the accusation S2 stated that they intentionally avoided being near R1 to reduce R1's delusion that S2 was taunting them. Additional staff interviews revealed that the situation was not plausible to have occurred and that certain details of R1's story were found to be proven false. Staff believed that R1's progression of cognition decline likely caused them to merge both factual and fictitious events together, creating a situation that did not happen. LPA interviewed R1 during an unannounced facility visit and R1 sustained that the incident occurred. However, R1 was not able to be completely qualified as a valid historian, due to R1 not being able to recall basic information, and offering statements during the interview that were implausible. Two outside sources familiar with R1 were contacted regarding the allegation. One outside source confirmed being told by R1 that the event occurred, however no additional information was provided to them to corroborate the claim such as witnesses, date, time etc. The second outside source did not respond to requests for interview. Facility records and medical records were reviewed regarding the allegation. The records revealed that R1 experienced a change in condition due to an acute infection, which resulted in unusual behavior and paranoia. Facility records showed that R1 was being monitored by staff due to the changes, and monitoring was continued throughout their medication regimen to resolve the infection. The evidence indicates that R1 was experiencing a change in condition resulting in a delusion due to an acute infection. Records and interviews revealed that the incident was implausible due to specific details provided by R1 being proven untrue, and record evidence that the staff member in question was neither working the day of the incident in question and was also no longer in the position claimed. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Resident Services Director Nae Brownell, to discuss the purpose of the visit. Today's visit is in response to two self-reported incidents submitted by the facility regarding a resident death and a resident who with a medical condition who is no longer able to meet their own insulin needs. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Resident Services Director Nae Brownell, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.

(Continued from LIC9099 p.1) Staff interviews revealed that the elopement was a new behavior for R1, as they were noted to be a low elopement risk and had not attempted to leave the facility unassisted before this incident. Staff interviews additionally revealed that the Licensee adjusted R1's supervision level after the incident by implementing alert charting (status checks with documentation) and escorting R1 to all events. The interviews revealed that staff provided the level of supervision consistent with R1's care plan, R1 experienced a change in condition by eloping for the first time, and the Licensee immediately adjusted the care level/supervision provided to R1 after the incident. R1 was interviewed regarding the incident. R1 was not able to recall why they left the facility or which door they exited through. R1 was only able to recall the events after the incident occurred. Outside source interviews did not refute or corroborate the allegation. Attempts were made to contact the party who assisted R1 in the community after the elopement, but the source did not respond to inquiries. A second outside source familiar with the facility was contacted and confirmed being aware of the incident. However, this source did not conduct an investigation or pursue any additional information regarding the incident. Review of facility and outside source records confirmed staff statements that while R1 was not allowed to leave the building unassisted, they were not a wandering risk. R1's Elopement Risk Assessments show that R1 was a low wandering risk. R1's Needs and Services Plan, as well as an acuity assessment, showed that R1 was completely independent, with the exception of being provided reminders for bathing, using their walker and attending activities. Charting Notes for R1 were absent of any elopement or wandering incidents for R1 prior to this event. The charting notes showed that the Licensee increased their assistance/supervision to R1 after the incident; R1 was placed on alert charting and escorted to all events after the incident. Records showed that R1 explicitly requested less supervision from staff by signing a waiver not to receive checks at night. During two unannounced facility visits, LPA directly observed all facility exits. LPA observed the exits for Assisted Living to be consistent with the needs and supervision level for independent Assisted Living residents. (Continued on LIC9099-C p.3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continued from LIC9099-C p.2) The information gathered during the investigation did not show that the Licensee provided inadequate supervision to R1, resulting in the elopement. The evidence shows that R1 did not have a history of elopement behaviors and experienced a change in condition, and that the facility immediately adjusted the care plan to accommodate. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Executive Director Angela Scott-Kapiloff, to discuss the purpose of the visit. Today's visit was to collect proof for the completed plan of corrections for deficiencies cited on 1/15/25 during the facility's annual inspection. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. The facility's plan of corrections was completed and the deficiency is cleared. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.

(Continued from LIC9099 p.1) Staff informed that the facility's required infection control protocols were put in place, including Personal Protective Equipment (PPE) carts placed outside of the affected residents' rooms, full PPE donned by staff assisting the affected residents, CDC signs placed on the affected residents' doors, notifications made to the affected residents' responsible parties and physicians, and Public Health notified. Interviews with staff revealed consistent knowledge of facility protocols regarding infection control procedures at the facility. The information provided by staff regarding the infection control protocols that were in place were corroborated by facility records. The facility's Illness Tracking Form during the timeframe of complaint showed that five (5) Covid-19 cases existed at the facility. The tracking showed that at most, two (2) residents were under isolation protocols concurrently. Narrative Charting Notes for the residents in question during the timeframe of complaint corroborated staff statements that the physicians and responsible parties for the residents in question were notified of the positive COVID-19 test results. The infection control process outlined by staff was corroborated by the facility's Infection Control Plan, dated 07/01/2023. The Infection Control Plan was absent of directives regarding when the community should be notified of positive Covid-19 cases. Outside source interview with the facility's infection control trainer revealed that the recommendation was for communities to be notified of COVID-19 when the facility reached outbreak status, which was three (3) or more cases occurring at the same time. The outside source did not express concern regarding the facility's adherence to Covid-19 protocols and regulations. Staff statements regarding contacting Public Health were corroborated through website tracking verification with date and timestamps. LPA directly observed the facility's infection protocol specific to COVID-19. LPA observed the use of PPE, disinfectant and sanitation practices, and CDC signage. The observations made by LPA were consistent with staff interviews, outside source interviews, and records review. The investigation did not produce evidence that the Licensee did not follow their infection control notification policy. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Memory Care Director Parris McDaniel, to discuss the purpose of the visit. Today's visit is in response to the self reported incident of Resident 1 (R1 - see LIC811 Confidential Names List) who exited the facility without staff knowledge or assistance. LPA interviewed staff and residents and collected records. A wellness check was completed; no health or safety issues were identified. An exit interview was conducted with Memory Care Director Parris McDaniel, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22).  Their signature confirms receipt of these documents.

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers were granted entry into the facility by Executive Director Angela Scott-Kapiloff after identifying herself and stating the purpose of the inspection. The facility serves elderly residents, age 60 and above, 101 whom may be non-ambulatory. There is an approved Hospice Waiver for 18 residents. The facility is approved for delayed egress. LPA was accompanied by Scott-Kapiloff for a tour of the facility which was conducted inside and out and included a sample of resident units, the dining area and recreation rooms. There is a fire signal system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted on December 2023. Exterior and interior passageways were free from obstructions. Pull cords, sensor alerts with pendants are present in the facility. LPA observed functionality of signal system. Resident and facility room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [Continued from 809] Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. Medication room is located on the first floor and second floor. The medication carts were locked and stored in the medication rooms. Medications were labeled and kept in compliance with label instructions. LPA interview confirmed the licensee provides assistance in meeting medical and dental needs. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA also conducted a review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. There is a designated movie room, designated art/craft room and a garden activity patio along with gathering areas throughout the facility. At the time of visit, LPA observed a large group activity taking place on both the main floor and memory care unit. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were sited at the time of visit. A final exit interview and a copy of this report, Licensee/Appeal Rights - LIC 9058 (rev. 01/16), were provided to , Executive Director Scott Kapiloff whose signature on this form acknowledges receipt of these documents.

Licensing Program Analysts (LPAs) Amy Rodgers and Juliana Barfield conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Angela Scott-Kapiloff. During today’s visit, LPAs briefly toured the facility, reviewed staff and resident records, and interviewed staff and residents. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. An exit interview was conducted with the Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.