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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608029
Report Date: 07/07/2026
Date Signed: 07/07/2026 12:55:28 PM

Document Has Been Signed on 07/07/2026 12:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR/
DIRECTOR:		SUZETTE JOHNSONFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 300CENSUS: 224DATE:
07/07/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Executive Director - Suzette JohnsonTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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On 07/07/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit. The purpose of this visit is to deliver deficiencies observed during the course of the investigation regarding complaint control number 11-AS-20260122103758. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility.

Deficiencies observed were as follows:

Record review of the facility Plan of Operation revealed the following:
· “Medication Refills…Medication refills will be obtained in a timely manner to ensure residents have all physician ordered medication available. 1. The designated staff member contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to running out of medication…When the medication is ordered it entered onto the Refill Roster…3. Medications are never allowed to run out.”
· “Missed or Refused Medications…1. Missed/refused medications are documented in the resident’s medication record…”
· “Blood Pressure and/or Pulse Reading to Determine the Need for a Medication…resident’s vital signs are taken to determine the need for admiration of medications: a)…A written record is made on the MAR. b) When the medication is given, the date, time, and initials of the person who took the vital signs and/or gave the medication are documented.
· “Assisting with Administration: Oral Medications…5. Document administration of medication on them Medication Assistance/Administration Record.”
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 07/07/2026
NARRATIVE
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On 04/10/2026, resident MARs were reviewed along with their medications in the Memory Care Unit and Assisted Living Unit and the following was revealed:

· Resident 2 (R2) did not have their prescription or nonprescription PRN medication available to them which was “Hyoscyamine 0.125 mg tab”. MedTech was unable to locate PRN medication.

· Resident 15’s (R15) March 2026 MAR shows the following:
o “Furosemide 40 mg tablet – take 1 tablet by mouth daily for CHF Hold for SBP <110”
§ On 03/01/2026 medication was not provided to R15 and Blood Pressure (BP) was not documented.
§ On 03/05/2026 medication was provided to R15 and BP was not documented.
§ On 03/25/2026 medication was provided to R15 and BP was not documented.
o “Digoxin 125 mcg tablet – take 1 tablet by mouth once daily at 12 PM for a-fib (Hold if apical pulse below 60)”
§ On 03/05/2026 medication was provided to R15 and pulse was not documented.
§ On 03/25/2026 medication was provided to R15 and pulse was not documented.
§ On 03/31/2026 medication was provided to R15 and pulse was not documented.
o “Sacubitril-Valsartan 24-26 mg – take 1 tablet by mouth twice daily (hold if sbp below 110)”
§ On 03/01/2026 at 8:00 AM R15 medication was not provided to R15 and BP was not documented.
§ On 03/05/2026 and 03/25/2026 at 8:00 AM R15 medication was provided to R15 and BP was not documented.
§ On 03/05/2026, 03/06/2026, 03/07/2026, 03/13/2026, 03/14/2026, 03/29/2026, and 03/31/2026 at 5:00 PM R15 medication was provided to R15 and BP was not documented.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 07/07/2026
NARRATIVE
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·Resident 16 (R16) April 2026 MAR shows the following:
o “Vitamin D3 50,000 unit capsule – take capsule by mouth once weekly on Fridays” was not available to R16. MedTech was unable to locate the routine medication. Records reviewed revealed that a refill was not submitted and no notes were written.
o “Alum-Mag Hydroxide-Simeth Susp” – PRN medication was not available for R16. MedTech was unable to locate PRN medication. Said medication has not been provided to the resident.
o “Loperamide 2 mg capsule” - PRN medication was not available for R16. MedTech was unable to locate PRN medication. Said medication has not been provided to the resident.
o “Milk of Magnesia Suspension” - PRN medication was not available for R16. MedTech was unable to locate PRN medication. Said medication has not been provided to the resident.

· Resident 7 (R7) April 2026 MAR shows the following:
o “Pantoprazole sod dr 40 mg tab – Take 1 tablet by mouth twice daily before meals for 14 days.”
§ There were 9 medication errors for this medication.
§ The medication bubble states that the medication was dispensed on “03/28/2026” with “no refills” and a “quantity of 28 tablets” (28 divided by 14 equals a total of 14 days of medication, the last day of the medication would have been 04/10/2026 if R7 started to take medication in the morning of 03/28/2026); the bubble pack has an “AM” sticker. There is no bubble pack with a “PM” sticker. The April 2026 MAR shows that R7 received medication at 8 AM and 5 PM from 04/01/2026 to 04/09/2026 and R7 refused 8 AM medication on 04/10/2026. The bubble pack has 12 tablets popped out and 16 tablets in the bubble pack (there should have been one more tablet left over if R7 started to take medication in the morning of 03/28/2026). According to interviews with staff in the Medication Room, they only provide this medication to R7 at 8 AM but not at 5 PM. Physicians Orders and Hospice records confirmed that this medication was prescribed to be taken twice a day for 14 days.

· Resident 10 (R10) April 2026 MAR shows the following:


o There are 14 medication errors.
§ 14 Medication bubble packs for “AM” are popped out for 04/09/2026.
§ April 2026 MAR for 04/09/2026 at 8 AM are left blank with no initials for 14 different medications.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 07/07/2026
NARRATIVE
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· Resident 13 (R13) April 2026 MAR shows the following:
o 2 routine medications were not found in the Medication Room; MedTechs were unable to locate the medications. According to MAR the resident has been taking the medication as prescribed. The medications were “Spiriva Handihaler 18 mcg cap” and “Bacitracin 500 unit/gm ointment.” Physician’s Orders confirmed that said medications were prescribed.
o 8 PRN medications were not found in the Medication Room; MedTechs were unable to locate the medications. Physician’s Orders confirmed that said medications were prescribed. Said medications have not been provided to the resident.

Deficiencies are being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809D.



An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Suzette Johnson.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2026 12:55 PM - It Cannot Be Edited


Created By: Socorro Leandro On 07/07/2026 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2026
Section Cited
CCR
87208(a)

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Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
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Executive Director has agreed to review the facility’s Plan of Operation regarding medication and train MedTechs & LVNs.

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Based on observations, interviews, and record review the licensee did not comply with the section cited above by not following the facility’s Plan of Operation and not providing medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.
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Confirmation of reviewed Plan of Operation regarding medication and trainings shall be emailed to Socorro.Leandro@dss.ca.gov

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2026


LIC809 (FAS) - (06/04)
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