197608029-9-20-2021-11-AS-JHAD-C7BR9R-20210929124958

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 09/20/2021
Date Signed: 09/20/2021 03:52:47 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
08/19/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210819151330

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:	01:33 PM
MET WITH:	LICENSEE JAMES BENDER		TIME COMPLETED:	01:34 PM

ALLEGATION(S):

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Staff are not meeting residents dietary needs

INVESTIGATION FINDINGS:

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On 09/15/2021 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 Reggie Jones.

The Investigation consisted of the following: On 08/20/2021 LPA Calderon reviewed all complaint notes. On 08/26/2021 LPA Calderon interviewed Administrator Reggie Jones 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, Physicians Report. On 08/26/2021 LPA Calderon interviewed staff S2-S3 regarding complaint and on 08/26/2021 LPA Calderon interviewed R1-R5 for complaint. Finally, LPA Calderon interviewed S4 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: 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-20210819151330

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: Staff are not meeting residents’ dietary needs
It is alleged on facility Staff are not meeting residents’ dietary needs. On 08/26/2021 LPA Calderon interviewed S1 who states that he has been working with R1 for some time regarding her diabetic meals and that R1 is very picky regarding what she eats and changes her mind many times. S1 states that they do follow the doctor’s instruction and that R1 changes the meal plan all the time. S1 states that R1 has mental issues and they are aware of her issues. LPA Calderon interviewed R1 who claimed staff has been feeding her greasy food for many months and that she must purchase food so that she does not starve herself. R1 states that the facility does not follow her doctor’s instruction and she must change what the facility kitchen sends to her daily.

On 08/26/2021 LPA Calderon interviewed R2-R4 all confirm the food could be better but that the kitchen does follow their doctors’ instructions and they have many choices of food to pick every day and they do not have any issues with the food. LPA Calderon interviewed S2-S4 all confirm issues with R1 regarding her food and her overall care by staff. Staff confirms that they make sure to follow the doctor’s instructions regarding R1 food, but that R1 changes her mind many times and they cannot keep up with what R1 is requesting to eat. On 08/20/2021 LPA Calderon reviewed R1 facility medical information, confirmed R1 has dementia and sees things that are not there.
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 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: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

LIC9099 (FAS) - (06/04)

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