197608029-8-5-2020-11-AS-JHAD-BSFMHA-20200813093713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 07/30/2020
Date Signed: 08/05/2020 08:49:58 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2020 and conducted by Evaluator Ulysses Coronel

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200526120258

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	BRAD DEHAAN		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS:	DATE:	07/30/2020
		UNANNOUNCED	TIME BEGAN:	08:32 AM
MET WITH:			TIME COMPLETED:	09:03 AM

ALLEGATION(S):

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Resident had access to medications resulting in overdose

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Brad DeHaan, the facility administrator.

On 06/02/2020 LPA conducted telephone interviews with the administrator Brad DeHaan and resident care director Sidonia Cordis, a video call which consisted of a review of resident R1's bedroom and the facility's med room. The LPA also requested copies of staff's work schedule and residents R1 and R2's resident records. On 06/09/2020 LPA conducted videocall interviews 11 out of 212 residents. On 07/24/2020 LPA conducted record reviews of R1’s hospital medical records. On 07/24/2020 LPA conducted staff interviews with Resident Care Director (RCD) Sidonia Cordis, Med Tech Supervisor (MTS) Chei Wei Miao and 4 out of 6 Med Tech staff.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020

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 11-AS-20200526120258

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 07/30/2020

NARRATIVE

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The investigation revealed the following: On 05/23/2020 R1 was found at the facility with altered mental status. EMS found empty bottles of medications and several pills at victim's bedside. 911 was called, R1 was taken to Long Beach Memorial Hospital. On 05/26/2020R1 returned to the facility. On 06/02/2020 Resident Care Director Cordis indicated that “R1 is alert oriented independent, no dementia, showers and dresses independently, able to set own doctors’ appointments, and arrange transportation. On 06/09/2020 6 out of 11 residents interviewed (R1, R3, R6, R7, R8 and R11) were having their medications managed by the facility, all 6 residents which included R1 did not have any concerns regarding medication management. On 07/03/2020 LPA conducted review of R1’s resident record and observed that R1 was admitted to the facility on 04/29/2015. On 07/24/2020 staff S2 stated that “I noticed an empty white medication bottle and around 10 pills near R1, the bottle had an old and faded label that read Kaiser and the expiration year was 2013." On 07/24/2020 MTS Miao stated that "I am the one who calls-in R1’s refills and all refills are either mailed directly to the facility or picked up from Kaiser pharmacy by myself or by the facility driver." On 07/24/2020 RCD Cordis stated that "I did not receive reports indicating any changes in R1, or of R1 having suicidal thoughts prior to the incident." On 07/28/2020 LPA interviewed R1 who stated that “I got them from a separate doctor from a long time ago.” “Those pills were 5 years old.” when LPA asked where R1 kept the pills R1 stated, “In my purse.”

Regarding the allegation: “Resident had access to medications resulting in overdose.” Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

A telephonic exit interview was conducted with Brad DeHaan, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020

LIC9099 (FAS) - (06/04)

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