197608029-10-4-2021-11-AS-JHAD-C7LM5L-20211008091831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 08/19/2021
Date Signed: 10/04/2021 03:06:58 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
02/09/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210209153410

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: 166	DATE:	08/19/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	ADMINISTRATOR JAMES BENDER		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident sustained serious injury while in care resulting in hospitalization.
Resident sustained many unwitnessed falls while in care.
Resident has mulitple unexplained scab wounds.

INVESTIGATION FINDINGS:

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On 08/18/2021 around 02:00 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 James Bender.

The Investigation consisted of the following: LPA Calderon conducted a tour of the physical plant. LPA 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) On 02/08/2021 LPA Calderon submitted facility records and client records and initial investigation report to the Department Investigation Branch (IB). On 02/11/2021 IB Investigator Lorraine Patterson conducted record reviews on the facility records, client records and initial investigation report submitted by LPA. On 05/11/2021 IB interviewed (W1). On 05/07/2021 IB interviewed (C3), On 5/17/2021 IB Investigator interviewed (S2), On 5/17/2021 IB Investigator interviewed (S2) and on 5/17/2021 IB investigator Administrator(C3).

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: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

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-20210209153410

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: 08/19/2021

NARRATIVE

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The investigation revealed the following:

Regarding the allegation “Resident sustained serious injury while in care resulting in hospitalization. All the parties IB interviewed W1, C1-C3, S1-S3 on 05/17/2021 denied any abuse and stated that R1’s injury was unwitnessed. IB was not able to interview R1 due to R1’s dementia. IB reviewed all hospital medical records did not report suspected neglect or abuse and could find any fault with facility.

Regarding the allegation: “Resident sustained many unwitnessed falls while in care”. All the parties IB interviewed on 05/17/2021, 5/17/2021, 5/17/2021 denied any abuse and stated that R1 has sustained unwitnessed falls. IB was not able to interview R1 due to R1’s dementia. IB reviewed records and interviews revealed that R1 needed reminders to call for help with transfers and R1 often tried to transfer alone and had unwitnessed falls. Safety plans and interventions such as physical therapy, bed rails, fall pad and alarm pendant, increase monitoring was agreed on with R1 family to aid in fall prevention. Based on the inform ion obtained and records review R1 has had multiple falls but the facility, family and doctor have fall risk plans in place to prevent falls.

Regarding the allegation: “Resident has multiple unexplained scab wounds”. All the parties IB interviewed on 05/17/2021, 5/17/2021, 5/17/2021 denied any abuse and stated that R1’s injury was unwitnessed. IB was not able to interview R1 due to R1’s dementia. IB reviewed records and interviews revealed R1 was ambulated with wheelchair and would sustain accidental bumps, bruised and skin tears from hitting the wheelchair. IB reviewed all medical records from the facility and hospital and could not find evidence of neglect from the facility.

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 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: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

LIC9099 (FAS) - (06/04)

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