197608029-7-29-2021-11-AS-JHAD-C6DVD2-20210830161959

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 07/29/2021
Date Signed: 07/29/2021 08:58:55 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
07/22/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210722163038

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: 180	DATE:	07/29/2021
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	ADMINISTRATOR BRAD DEHAAN		TIME COMPLETED:	09:15 AM

ALLEGATION(S):

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Lack of supervision resulting in resident being physically assaulted by another resident in care.
Facility did not seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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On 07/29/2021 around 10:00 am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA Calderon met with Administrator Brad DeHaan, Administrator and the purpose of the visit was explained.

The Investigation consisted of the following: On 07/23/2021 LPA Calderon interviewed witness for the complaint. On 07/23/2021 LPA Calderon interviewed Administrator Brad DeHaan and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, Resident 1 &2, Physicians Report, copy of Torrance Memorial Hospital Notes, SIR report on incident and viewed facility video or altercation. On 07/26/2021 LPA Calderon interviewed staff S1 regarding complaint and on 07/26/2021 LPA Calderon interviewed R1-R4 for complaint. On 07/27/2021 LPA Calderon interviewed S2-S3 for complaint.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 11-AS-20210722163038

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: 07/29/2021

NARRATIVE

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Allegation: Facility did not seek medical attention in a timely manner.
It is alleged that Facility did not seek medical attention in a timely manner. On 07/23/2021 LPA Calderon interviewed witness for the complaint and confirmed R1 had cuts and bruises on his face. Witness states that another resident attacked resident and video from facility clearly shows resident 2 attacking resident 1. Witness took resident 1 to the hospital for evaluation. Witness states that the facility did not take incident seriously and told witness that there was nothing wrong with resident. On 07/26/2021 LPA Calderon interviewed S1 who confirms the video of the fight between resident 1 and resident 2. S1 states that resident 1 attacked resident 2 due to resident 2 sitting on a sofa and words were exchanged and punches were thrown. S1 states that neither resident was injured, but a SIR report was taken, and confirmed both men stated that they were not injured from the altercation. On 07/26/2021 LPA Calderon interviewed R1-R4, resident 1 and 2 confirm the other resident started the fight for unknown reason, and that neither one has ever had any issues with the other one they are not clear what started the fight. Both resident 1 and 2 confirm no injuries and the police never spoke to them. Residents 3 and 4 also did not know what started the fight, but that resident 1 punched first and neither one was injured. On 07/27/2021 LPA Calderon interviewed S2-S3 and all confirm that resident 1 started the fight for unknown reason. Both staff members confirmed no injuries to either men and the fight was broken up by staff. On 07/27/2021 LPA Calderon received and reviewed: Physician's report which indicated R1 and R2 primary diagnosis is dementia. Reviewed Torrance Memorial Hospital reported dated 7/23/2021, hospital report does not support resident 1 was injured from the altercation with resident 2 but did have a heart issue not associated with the incident. Reviewed SIR report which does support staff breaking up the fight when they were aware of the issue between both men.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20210722163038

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: 07/29/2021

NARRATIVE

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Allegation: Lack of supervision resulting in resident being physically assaulted by another resident in care.
It is alleged that Lack of supervision resulting in resident being physically assaulted by another resident in care. On 07/23/2021 LPA Calderon interviewed witness for the complaint and confirmed R1 had cuts and bruises on his face. Witness states that another resident attacked resident and video from facility clearly shows resident 2 attacking resident 1. Witness took resident 1 to the hospital for evaluation. Witness states that the facility did not take incident seriously and told witness that there was nothing wrong with resident. On 07/26/2021 LPA Calderon interviewed S1 who confirms the video of the fight between resident 1 and resident 2. S1 states that resident 1 attacked resident 2 due to resident 2 sitting on a sofa and words were exchanged and punches were thrown. S1 states that neither resident was injured, but a SIR report was taken, and the police were called. S1 states police would not take a report due to both residents having dementia. On 07/26/2021 LPA Calderon interviewed R1-R4, resident 1 and 2 confirm the other resident started the fight for unknown reason, and that neither one has ever had any issues with the other one they are not clear what started the fight. Both resident 1 and 2 confirm no injuries and the police never spoke to them. Residents 3 and 4 also did not know what started the fight, but that resident 1 punched first and neither one was injured. On 07/27/2021 LPA Calderon interviewed S2-S3 and all confirm that resident 1 started the fight for unknown reason. Both staff members confirmed no injuries to either men and the fight was broken up by staff. On 07/27/2021 LPA Calderon received and reviewed: Physician's report which indicated R1 and R2 primary diagnosis is dementia. Reviewed Torrance Memorial Hospital reported dated 7/23/2021, hospital report does not support resident 1 was injured from the altercation with resident 2 but did have a heart issue not associated with the incident. Reviewed SIR report which does support staff breaking up the fight when they were aware of the issue between both men.

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.

An exit interview was conducted with Administrator Brad DeHaan, and a hard copy was provided. On 07/29/2021 around 12:00 pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA Calderon met with Administrator Brad DeHaan, Administrator and the purpose of the visit was explained.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC9099 (FAS) - (06/04)

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