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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 08/27/2026
Date Signed: 08/27/2026 04:03:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
08/12/2026 and conducted by Evaluator Socorro Leandro
COMPLAINT CONTROL NUMBER: 11-AS-20260812153030
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:SUZETTE JOHNSONFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 238DATE:
08/27/2026
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Executive Director - Suzette JohnsonTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff did not provide residents with medication as prescribed
INVESTIGATION FINDINGS:
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On 08/27/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced continuation complaint investigation visit regarding the allegation listed above. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility.

Investigation consisted of the following:

On 08/19/2026, interviews were conducted with Staff 1 (S1) to Staff 5 (S5) and Resident 1 (R1), and records were reviewed. On 08/27/2026, interviews were conducted with Staff 6 (S6) to Staff 8 (S8), and records were reviewed. Records reviewed consisted of Medication Administration Records (MARs) for R1 to Resident 4 (R4) along with their medications, Medical Assessments for R1 to Resident 3 (R3), Resident Roster, Staff Roster, and Unusual Incident/Injury Report dated 08/10/2026 for R1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
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 8
Control Number 11-AS-20260812153030
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/27/2026
NARRATIVE
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Allegation: “Staff did not provide residents with medication as prescribed.”

The investigation revealed the following:

Plan of Operation states 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.”
· “Permanent Discontinuance: Permanently discontinued medication will not be retained in the Community.”
· “Expired Medications: Expired medication will not be…retained in the Community.”
· “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.”
· “Assisting with Administration: Oral Medications…4. Assist resident with self-administration…b. Identify that this is the correct resident. Use photos if necessary as resident’s response may be inaccurate…5. Document administration of medication on the Medication Assistance/Administration Record.”
· “Assisting with Administration: Eyedrops…e. Identify that this is the correct resident. Use photos if necessary as resident’s response may be inaccurate. f. Allow resident to ask questions and provide appropriate answers. Be aware of body language and position. Sit next to resident at eye level and use calm voice…5. Document administration of medication on the Medication Assistance/Administration Record.”
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20260812153030
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/27/2026
NARRATIVE
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On 08/19/2026, R1 to R4’s MARs were reviewed along with their medications in the Memory Care Unit and Assisted Living Unit; medications were reviewed with the assistance of staff.

· Resident 1’s (R1) Medications

o Routine Medication - Acetaminophen 500 milligrams (mg) tablet
§ Medication was not found during the record review. Staff 1 (S1) indicated that the last time they provided said medication was on 08/10/2026 or 08/11/2026 because they do not know where the medication is located. (Later that day another Medtech assisted and was able to find R1’s medication).
§ MAR states that the medication was not recorded at 8:00 AM on 08/03/2026, 08/09/2026, 08/12/2026, 08/13/2026, 08/14/2026 & 5:00 PM at 08/03/2026, 08/09/2026, 08/10/2026, 08/13/2026, 08/16/2026, and 08/17/2026.
§ On 08/15/2026 MAR states “need to contact the pharmacy for refill.”
§ On 08/18/2026 MAR states “Refused.”

o Routine Medication - Donepezil HCL 5 mg tablet
§ Medication bottle was empty and S1 indicated that they request for a refill today.

o The following Prescription or Nonprescription PRN medications were not found during the record review: Chest Congestion Relief EM 10-100 mg/5 ml syrup; Ibuprofen 600 mg tablet; Melatonin 3 mg capsule; and sunscreen lotion.

o Unusual Incident/Injury Report dated 08/10/2026 states that 08/09/2026 at approximately 7:44 AM “resident was given the wrong medication. The resident was given a fellow residents medication.”
§ Staff 2 (S2) indicated that R1 received R3’s morning medications (R3 received their morning medication).
§ R1 indicated that they received another resident’s medication.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20260812153030
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/27/2026
NARRATIVE
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· Resident 2’s (R2) Medications

o Routine Medication – Cetirizine HCL 10 mg tablet
§ Medication was not found during the record review.
§ MAR states: on 08/07/2026 requested refill; on 08/14/2026 “out of stock”; on 08/15/2026 “waiting on medication”; medication provided on 08/03/2026 to 08/13/2026 and 08/16/2026 to 08/19/2026.
§ Staff 6 (S6) indicated that they did not provide medication on 08/19/2026.

o Routine Medication – Donepezil HCL
§ Medication was not found during the record review. Staff 3 (S3) indicated that they called this morning for a refill.

o No PRN medications were found during the record review.


· Resident 3 Medications

o Routine Medication – Prednisolone Acetate 1% Drops Susp
§ Medication was not found during the record review.
§ MAR states that the medication was not recorded at 8:00 AM on 08/03/2026, 08/06/2026, 08/09/2026, 08/14/2026, 08/17/2026 & 5:00 PM at 08/03/2026, 08/06/2026, 08/09/2026, 08/10/2026, 08/16/2026, 08/17/2026, 08/18/2026.
§ MAR states that on 08/04/2026 the medication was placed on hold and waiting for it to be discontinued.
§ MAR states that medication was provided at 8:00 AM on 08/05/2026, 08/07/2026, 08/08/2026, 08/10/2026 to 08/14/2026, 08/15/2026, 08/18/2026, and 08/19/2026 & 5:00 PM 08/04/2026, 08/05/2026, 08/07/2026, 08/08/2026, 08/11/2026 to 08/12/2026, 08/14/2026, and 08/15/2026.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20260812153030
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/27/2026
NARRATIVE
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· Resident 4 Medications
o The following medications were not found during the record review - Acetaminophen 500 mg tablet, Milk of Magnesia 400 mg/5 ml, and Glucosamine Relief 500 mg Capsule

Substantiated: Based on observations, interviews, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D.

An exit interview was conducted, a civil penalty was provided regarding repeat violation, appeal rights were reviewed, and plans of corrections were developed. A copy of this report was left with the Executive Director, Suzette Johnson.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20260812153030
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2026
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 create a plan and email said plan to Socorro.Leandro@dss.ca.gov
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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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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
08/12/2026 and conducted by Evaluator Socorro Leandro
COMPLAINT CONTROL NUMBER: 11-AS-20260812153030

FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:SUZETTE JOHNSONFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE:CAZIP CODE:
90806
CAPACITY:300CENSUS: 238DATE:
08/27/2026
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Executive Director - Suzette JohnsonTIME COMPLETED:
04:20 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff did not give resident their medication, resulting in hospitalization
INVESTIGATION FINDINGS:
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3
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5
6
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On 08/27/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced continuation complaint investigation visit regarding the allegation listed above. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility.

Investigation consisted of the following:

On 08/19/2026, interviews were conducted with Staff 1 (S1) to Staff 5 (S5) and Resident 1 (R1), and records were reviewed. On 08/27/2026, interviews were conducted with Staff 6 (S6) to Staff 8 (S8), Witness 1 (W1), and records were reviewed. Records reviewed consisted of Medication Administration Records (MARs) for R1 to Resident 4 (R4) along with their medications, Resident Roster, Staff Roster, Medical Records dated 07/19/2026 for R2, Unusual Incident/Injury Report (UIR) dated 07/23/2026 for R2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20260812153030
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/27/2026
NARRATIVE
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The investigation revealed the following:

Allegation: “Staff did not give resident their medication, resulting in hospitalization”, it is being alleged that R2 did not receive their medication and because of that they were hospitalized.

R2’s records reviewed revealed the following:

MAR dated 07/2026 indicated that on the morning of 07/19/2026 R2 received all their medication by Staff 7 (S7); S8 checked R2’s blood glucose at around 8:00 AM and 11:00 AM.

Medical Records dated 07/19/2026 showed that R2 went to the hospital and was observed at approximately 12:17 PM. R2 diagnoses was “Altered Mental Status and Transient Hypotension.” There is no documentation indicating that R2 did not take their medication, moreover, there is no clear explanation as to why R2’s mental status was altered nor why R2 had low blood pressure (transient hypotension). R2 was back to normal and cleared to back to the facility on 07/20/206 at approximately 12:14 AM.

Unusual Incident/Injury Report (UIR) dated 07/23/2026 states at on 07/19/2026 at approximately 11:41 AM R2 was observed drooling, staff called 911 and transported to Long Beach Memorial Hospital for further evaluation.

Interviews conducted revealed the following:

An interview was attempted with R2. R2 was observed to be well groomed and appropriately dressed.

S7 indicated that on 07/19/2026, R2 received all their medication. S7 goes on to explain that R2 does not have a history of refusing medication.

S8 indicated that on 07/19/2026, R2 received all their medication, and they checked R2’s blood sugar.
W1 was unable to provide additional information regarding the allegation.

Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of this report was left with the Executive Director, Suzette Johnson.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8