197608029-10-4-2021-11-AS-JHAD-C7LM4Y-20211008091729

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 08/19/2021
Date Signed: 10/04/2021 03:09:39 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
01/26/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210126160314

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 multiple pressure injuries while in care.
Resident sustained multiple falls while in care.
Staff did not give resident medication as prescribed.
Resident was severely dehydrated.
Staff did not ensure resident was fed.
Staff did not notify authorized representative of resident's change of health.
Staff did not safeguard resident's personal belongings.

INVESTIGATION FINDINGS:

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On 08/19/2021 around 1pm 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: On 02/10/2021 LPA Calderon interviewed S1-S4 and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Dermatology medical records, Physicians Report and Medication list for R1. On 02/11/2021 LPA Calderon interviewed (W1). On 02/11/2021 LPA Calderon interviewed W2. On 02/19/2021 LPA Calderon interviewed Residents R2 – R11. IB interviewed S1 on 02/24/2021, RN W1 on 03/01/2021, S2-S4 on 04/16/2021. IB reviewed medical records on 02/21/2021 and LPA Calderon reviewed all facility paperwork on 04/27/2021

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: 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)

Page: 1 of 3

Control Number 11-AS-20210126160314

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:

Allegation: Resident sustained multiple pressure injuries while in care.
IB investigator reviewed R1 medical records and conducted interviews with witnesses and facility staff. Review of Hospital records and photographs document a sacral area and a perirectal area wound. However, there is no information that these wounds were formally staged. The first charting of the sacral area wound was not until R1 had been hospitalized for approximately 34 hours. Information obtained from Witness #1 (W1) supports the possibility that the wound could have developed in the hospital, not necessarily while in the care of Vista Del Mar. Review of R1 facility record does not document pressure injuries or wounds. The Administrator and facility staff were interviewed and denied R1 having multiple pressure injuries.

Allegation: Resident sustained multiple falls while in care.
IB Investigator interviewed W1 to obtain professional opinion is that R1 did sustain multiple witnessed falls is June and July which were not reported by the facility but did not see any evidence there were multiple unreported falls suffered by R1. LPA Calderon interviewed S1-S4 and all confirm that R1 did have falls due to age, not waiting for staff while moving from wheelchair to bed. According to records reviewed R1 required prompts to not move out of wheelchair or bed with out assistance due to R1 dementia. The facility conducted a fall risk assessment in conjunction with R1 family and the falls were being addressed.

Allegation: Staff did not give resident medication as prescribed.
It is alleged staff did not give resident medication as prescribed. LPA Calderon interviewed S1-S4 all confirm that R1 medication was given correctly and there was no mistake with R1 MAR. LPA Calderon interviewed R2-R11 and all confirm no issues with medication and staff does a great job. LPA Calderon reviewed resident medications and Medication Administration Record and did not observe any discrepancies.

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)

Page: 2 of 3

Control Number 11-AS-20210126160314

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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Allegation: Resident was severely dehydrated.
IB review of records revealed the facility documented their attempts to provide R1 fluids, although her oral intake abilities were diminishing as her dementia progressed. She was also on a diuretic medication. W1 stated that R1 was most likely dehydrated when she got to the hospital, but it was not a result of staff neglect at Vista Del Mar. The facility staff and Administrator denied neglect and stated R1 was provided fluids but was difficult for R1 to intake due to decline in health.

Allegation: Staff did not ensure resident was fed.
LPA Calderon interviewed S1-S4 and all confirm resident was given food, but R1 sometimes refused to eat. LPA Calderon interviewed R2-R11 and all residents confirm3 meals a day and no issues with food. Review of records revealed R1 was declining and often refused food.

Allegation: Staff did not notify authorized representative of resident's change of health.
LPA Calderon interviewed S1-S4 and all confirm communication with POA for R1 and any change of health was advised in writing. LPA Calderon interviewed R2-R11 all residents confirm that their families are given updated regarding their change in health.

Allegation: Staff did not safeguard resident's personal belongings.
LPA Calderon interviewed S1-S4 all confirm that R1 personal items were safe and no one stole the belongings. LPA Calderon interviewed R2-R11 and all confirm that no one has ever stole any of their personal items.

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 telephonic exit interview was conducted with Administrator James Bender, and a hard copy was provided face to face for records.

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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