197608029-9-21-2021-11-AS-JHAD-C7BRWK-20210929132316

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 09/20/2021
Date Signed: 09/21/2021 03:07:03 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
09/14/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210914155451

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: 181	DATE:	09/20/2021
		UNANNOUNCED	TIME BEGAN:	11:13 AM
MET WITH:	LICENSEE JAMES BENDER		TIME COMPLETED:	11:14 AM

ALLEGATION(S):

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Facility has bed bugs
Facility did not report an unusual incident

INVESTIGATION FINDINGS:

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On 09/20/2021 around 11:00 am 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 Licensee James Bender.

The Investigation consisted of the following: On 9/20/2021 LPA Calderon interviewed reporting party. On 09/20/2021 LPA Calderon interviewed Licensee James Bender and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, R1-R2 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, plus VA hospital records. On 09/20/2021 LPA Calderon interviewed staff S2-S4 regarding complaint and on 09/20/2021 LPA Calderon interviewed R1-R5 for complaint.

The investigation revealed the following:

Substantiated

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: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

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-20210914155451

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: 09/20/2021

NARRATIVE

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Allegation: Facility has bed bugs
It is alleged on Facility has bed bugs. On 09/20/2021 Responsible Party (RP) was informed by the VA Hospital that R1 had bed bugs bites and a rash and was treated medically. Reporting party states that social services for the VA was not informed by the facility prior to the medical report. On 09/20/2021 LPA Calderon interviewed S1 who confirmed R1 did in fact have bed bugs and contracted the beds from R2. On 09/20/2021 LPA Calderon interviewed S2-S4 who all confirm that R1-R2 had bed bugs. On 09/20/2021 LPA Calderon interviewed S2-S5 who can confirm beds in the past but no current issues. On 09/20/2021 reviewed facility paperwork and VA hospital paperwork which confirmed R1 had bed bugs.

Allegation: Facility did not report an unusual incident
It is alleged on facility did not report an unusual incident. On 09/20/2021 LPA Calderon interviewed reporting party who confirmed facility did not report the bed bugs to social services VA and have been informed of same in the past. On 09/20/2021 LPA Calderon interviewed S1 who confirmed they did not report the bed bugs to social services of DSS prior to the complaint being generated. On 09/20/2021 LPA Calderon interviewed S2-S4 who all confirm they did report the bed bugs to upper management and does not know if upper management reported the bugs to social services VA or DSS.

Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

A exit interview was conducted with Licensee James Bender, 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: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20210914155451

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/01/2021 Section Cited CCR 87303(A)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by	1 2 3 4 5 6 7	Administrator will follow protocols of Department of Public Health. Administrator will provide copy of actions taken by' facility based on Department of Public Health's instructions. Due date 10/01/2021.
	8 9 10 11 12 13 14	Based on records reviewed and interviews conducted the licensee failed to ensure Residents #1 was afforded a safe and comfortable accommodations. R1 was infected with bed bugs while in placement at facility. This poses a health & Safety risk to residents in care.	8 9 10 11 12 13 14
Type B 10/01/2021 Section Cited CCR 87211(A)(2)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(2) Occurrences, such as epidemic outbreaks... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will ensure additional training regarding proper reporting from staff to upper management to reporting parties. Administrator shall submit to LPA by POC
	8 9 10 11 12 13 14	Based on records reviewed and interviews conducted the licensee failed to report the bed bug outbreak to VA social services or Department of Social Services. This poses a health & Safety risk to residents in care.	8 9 10 11 12 13 14

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC9099 (FAS) - (06/04)

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