197608029-7-1-2021-28-AS-MVAO-C5ZM2G-20210818091330

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 07/01/2021
Date Signed: 07/01/2021 02:28:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/03/2020 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200303161026

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: 174	DATE:	07/01/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Brad DeHaan, Sidonia Cordis		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Resident did not receive their medications on several occasions.
Resident did not receive their medications on a timely basis.
Staff does not keep accurate resident medication records.
Unqualified staff administered resident medication.
Staff threatened residents.
Resident was illegally evicted.
Staff failed to contact family in a timely manner following resident's death.

INVESTIGATION FINDINGS:

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Licesning Program Analysts (LPAs) Nicol Wesley and Luis Mora conducted an unannounced subsequent visit at the facility and met with Administrator Brad Dehaan and Residential Care Director Sidonia Cordis to discuss the purpose for todays visit.

Investigation consisted of the following: On 03/11/2020 LPA Wesley requested a copy of the staff roster, resident roster to review resident #1's file, Unusual Incident Reports from 2019, Medication Administration Records from May 2019 through August 2019, and requested copies of specific documents. LPA interviewed staff and residents.

Investigation revealed the following: Regarding allegation: Residents did not receive their medications on several occasions, Resident did not receive their medications on a timely basis, Staff does not keep accurate resident medication records, and unqualified staff administered resident medication. LPA Wesley and Mora requested to see a copy of random selected residents medication records including records for resident #1 as
continued on LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

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 28-AS-20200303161026

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 07/01/2021

NARRATIVE

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specific names were not provided. During the investigation, LPAs did not observed there to be any missed medication missed medications, medication errors and medication was issued timely according to the physicians orders with the exception of 07/10/2019, when the evening staff(Med Tech)who was in charge of medication dispensing had to leave the facility for a family emergency and was not able to dispense the residents evening medication. LPAs did not observed there to be any additional blank boxes on the medication logs in a four month time span. The facility Administrator notified the licensing agency via special incident reported dated 07/12/2019, and also notified other parties of the occurrence and later issued the medication according to the Physicians instructions. The investigation also revealed that the staff who are assigned to issue residents medications have received Medication Technician certification training and successfully passed the required examination.
Regarding allegation: Staff threatened residents. Interviews were conducted with randomly selected residents as no specific names were provided. Residents advised that they are able to address their concerns and have never been threatened by any of the facility staff or the Administrator and have never witnessed any other residents being threatened by facility staff or the Administrator. Staff were interviewed and advised that they have never threatened any of the residents or have never witnessed any other staff or the Administrator threaten the residents.
Regarding allegation: Resident was illegally evicted. During interviews with the Administrator and Residential Care Director, it was discovered that resident #1 was hospitalized on 09/01/2019. During treatment, testing, and evaluation, it was determined by resident #1's treating Physician that resident #1 required placement in a 24/7 locked community in which Vista Del Mar is not licensed to provide care for the resident #1's specific needs. Resident #1's Power of Attorney(POA) was aware of the situation and removed their loved ones belongings on 09/28/2019 and was issued a refund according to the resident move-out form. There is no evidence to support the allegation that resident #1 was illegally evicted.
Regarding allegation: Staff failed to contact family in a timely manner following resident's death. The investigation revealed that the death of the resident(unknown name) that was referenced was based on a conversation a party overheard staff speaking about in which the facility staff was not privy to disclose personal information to a non-family member due to resident confidentiality and privacy laws. The unknown residents cause of death was not revealed and it was questioned that the cause of death was a result of the unknown resident not receiving medication the night before. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.
There were no deficiencies cited. A copy of the LIC 9099/LIC 9099C was given during the exit interview.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

LIC9099 (FAS) - (06/04)

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