197608029-5-28-2021-11-AS-JHAD-C6UU8U-20210914152207

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 05/28/2021
Date Signed: 05/28/2021 01:36:16 PM

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
04/21/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210421115155

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: 172	DATE:	05/28/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Administrator Brad DeHaan		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are not following physician's orders to place a resident in a private room
Staff are not following physician's orders for showering a resident

INVESTIGATION FINDINGS:

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On 05/28/2021 around 12:00 pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Brad DeHann.

The Investigation consisted of the following: On 05/18/2021 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’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Dermatology medical records, Physicians Report and Medication list) and housekeepers training documentation and cleaning procedures. On 05/18/2021 LPA Calderon interviewed staff S2-S9 regarding complaint and on 05/18/2021 LPA Calderon interviewed R1-R10 for complaint.

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: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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 11-AS-20210421115155

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: 05/28/2021

NARRATIVE

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The investigation revealed the following:

Allegation: Staff are not following physician's orders to place a resident in a private room
It is alleged on facility Staff are not following physician's orders to place a resident in a private room. On 04/21/2021 Responsible Party (RP) was informed by Administrator that she had not paid for a private room. On 05/17/2021 LPA Calderon reviewed facility paperwork: Assisted Living Waiver (amenity form) date 9/8/2016, R1 waived her right to private room, refrigerator and microwave, Shower schedule, 4 groups, R1 is in group 1, room 271 shower given Monday group 1, Wednesday group 4 and Saturday group 4. Admission agreement, normal charges for resident care. On 05/18/2021 LPA Calderon interviewed R1 who states that staff is not following her doctors’ orders. On 05/18/2021 LPA Calderon interviewed S1-S9 who all confirm that they follow all doctors’ orders for R1 and that resident 1 is hard to please. On 05/18/2021 LPA Calderon interviewed R2-R10, all confirm no issues with service, food, showering, medication.

Allegation: Staff are not following physician's orders for showering a resident
It is alleged on facility Staff are not following physician's orders for showering resident. On 05/17/2021 LPA Calderon reviewed facility paperwork: Assisted Living Waiver (amenity form) date 9/8/2016, R1 waived her right to private room, refrigerator and microwave, Shower schedule, 4 groups, R1 is in group 1, room 271 shower given Monday group 1, Wednesday group 4 and Saturday group 4. Admission agreement, normal charges for resident care. On 05/18/2021 LPA Calderon interviewed R1 who states that staff is not following her doctors’ orders. On 05/18/2021 LPA Calderon interviewed S1-S9 who all confirm that they follow all doctors’ orders for R1 and that resident 1 is hard to please. Staff state that R1 refuses to take her shower when all other resident takes their shower around 11am. Staff also confirms that R1 refuses most food given to her. On 05/18/2021 LPA Calderon interviewed R2-R10, all confirm no issues with service, food, showering, medication.

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.

A exit interview was conducted with Administrator Brad DeHann, and a hard copy was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

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