197608029-10-4-2021-11-AS-JHAD-C7LMKW-20211008094125

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 05/28/2021
Date Signed: 10/04/2021 03:03:15 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
03/23/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210323090543

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:	01:19 PM
MET WITH:	Administrtor Brad DeHaan		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee did not bathe resident\
Licensee did not groom resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 05/24/2021 around 1pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA met with Brad DeHaan, Administrator and the purpose of the visit was explained.

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-S8 regarding complaint and on 05/18/2021 LPA Calderon interviewed R1-R10 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: 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)

Page: 1 of 3

Control Number 11-AS-20210323090543

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Licensee did not bathe resident
It is alleged that R1 family pays extra money for R1 to be given a shower 2 or 3 times a week, and that is not being done since every time resident is visited, R1 is dirty and wearing dirty clothes. It is also alleged R1 has scabies and that she is paying for cleaning services. On 04/05/2021 LPA Calderon attempted to interview R1 but was unsuccessful as R1 has dementia and was unable to answer questions. On 04/05/2021 LPA Calderon interviewed R2-R10, 9 out of 10 residents stated they have no issues with showering, some get assistance from staff, most can shower on their own. All residents deny the presence of scabies, all their rooms are cleaned weekly and service is good. On 04/05/2021 LPA Calderon interviewed S1-S5 deny scabies in the facility and stated they have schedule for showering and that there are no issues reported. On 04/09/2021 LPA Calderon received and reviewed facility paperwork: Physician's report which indicated R1 cannot self-bath. Clean schedule 2021, extensive cleaning schedule for facility, Reviewed Orkin paperwork, service 1/11/2021 treated rooms 132, 259, 271,303 no scabies found. On 2/1/2021 treated facility and no bugs, scabies found, 3/1/2021 treated rooms 126138, 271,322 no bugs or scabies found. 3/21/2021 doctors’ script for R1, appears to be infect bite. reviewed MAR, extensive information notes no issues noted.

Allegation: Licensee did not groom resident
It is alleged that R1 family pays extra money for R1 to be given a shower 2 or 3 times a week, and that is not being done since every time resident is visited, R1 is dirty and wearing dirty clothes. It is also alleged R1 has scabies and that she is paying for cleaning services. On 04/05/2021 LPA Calderon attempted to interview R1 but was unsuccessful as R1 has dementia and was unable to answer questions. On 04/05/2021 LPA Calderon interviewed R2-R10, 9 out of 10 residents stated they have no issues with showering, some get assistance from staff, most can shower on their own. All residents deny the presence of scabies, all their rooms are cleaned weekly and service is good. On 04/05/2021 LPA Calderon interviewed S1-S5 deny scabies in the facility and stated they have schedule for showering and that there are no issues reported. On 04/09/2021 LPA Calderon received and reviewed facility paperwork: Physician's report which indicated R1 cannot self-bath. Clean schedule 2021, extensive cleaning schedule for facility, Reviewed Orkin paperwork, service 1/11/2021 treated rooms 132, 259, 271,303 no scabies found. On 2/1/2021 treated facility and no bugs, scabies found, 3/1/2021 treated rooms 126138, 271,322 no bugs or scabies found. 3/21/2021 doctors’ script for R1, appears to be infect bite. reviewed MAR, extensive information notes no issues noted.

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)

Page: 2 of 3

Control Number 11-AS-20210323090543

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	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 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)

Page: 3 of 3