197608029-1-27-2026-11-AS-JHAD-DRQ2TV-20260227164123

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 01/27/2026
Date Signed: 01/27/2026 03:32:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/15/2026 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20260115161934

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	SUZETTE JOHNSON		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS: 247	DATE:	01/27/2026
		UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Interim Executive Director Collene Rozatti		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Questionable death.
Staff did not seek medical attention for resident.

INVESTIGATION FINDINGS:

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On 01/27/26 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit for the allegation(s) above. LPA met with Interim Executive Director Collene Rozatti (S1) as the purpose of the visit was explained.

The investigation consisted of the following: On 01/20/26 LPA obtained copies of the resident and staff rosters, as well as the following for resident #1 (R1): Emergency ID form, Admission Agreement dated: 09/14/25, Pre -appraisal, Physician Report dated: 09/18/25, Individual Service Plan, Physicians orders, facility notes, and a list of all staff that worked from 01/01/26- 01/05/26, and Administration Records (MAR) for 11/01/25- 01/2026. LPA also obtained a copy of the physicians attestation form dated: 01/14/26. On 01/20/26 and 01/27/26 LPA conducted interviews with staff #1-6 (S1-S6), and on 01/27/26 from 11am-12:30pm LPA conducted interviews with resident #2-11 (R2-R11). On 01/27/26 LPA conducted a review of of R1's file.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026

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-20260115161934

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 01/27/2026

NARRATIVE

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Allegation: Questionable death.
It is being alleged that facility staff did not respond or take appropriate action when resident in care requested medical assistance, which resulted in residents death. On 01/20/26 and 01/27/26 LPA conducted interview with S1-S6 regarding the allegation above. 6 of the 6 staff interviewed denied the allegation above and reported staff do not refuse to call 911 when needed. Additionally, 6 of 6 staff reported that a nurse or med tech will conduct an assessment when a resident is feeling unwell. On 01/27/26 from 11am-12:30pm LPA conducted interviews with R2-R11 regarding the allegation above. 6 of the 10 residents interviewed denied the allegation above and reported that facility staff assist them when assistance is requested. 1 of 10 residents interviewed confirmed the allegation above and reported that staff does not provided assistance when needed. 3 of 10 residents interviewed reported they have not had the need to ask for assistance but state they believe the staff would provide assistance. On 01/27/26 LPA conducted a review of R1's file. LPA observed that the physicians report dated: 09/18/25 indicates that R1's primary diagnosis were: acute and chronic respiratory failure with hypoxia, COPD, diabetes mellitus type 2, hypertensive heart disease with heart failure,dysphagia, muscle weakness, morbid obesity due to excess calories, difficulty walking, incentive spirometry, CPAP, and oxygen via nasal canula. On 01/27/26 LPA conducted a review of physicians attestation form dated: 01/14/26. Per attestation form the immediate cause of death was a cardiac arrest.

Allegation: Staff did not seek medical attention for resident.
It is being alleged that facility policy prohibits caregivers from calling 911 directly. On 01/20/26 and 01/27/26 LPA conducted interview with S1-S6 regarding the allegation above. 6 of 6 staff denied the allegation above and reported that caregivers are allowed to call 911 in an emergency situation and to not wait until they find a med tech or nurse to call 911. Additionally, 4 of 6 staff interviewed reported that a meeting was held where caregivers were told that they are allowed to call 911 when needed. On 01/27/26 from 11am-12:30pm LPA conducted interviews with R2-R11 regarding the allegation above. 6 of 10 residents interviewed denied the allegation above and reported that staff have not refused to call 911 when needed. 4 of the 10 residents interviewed reported they have not needed 911 to be called but believe staff would call 911 if needed.

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.

Exit interview conducted, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026

LIC9099 (FAS) - (06/04)

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