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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 12/01/2021
Date Signed: 12/02/2021 08:49:33 AM



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
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2020 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20201210140829
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:BRAD DEHAANFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 184DATE:
12/01/2021
UNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Reggie Jones TIME COMPLETED:
04:51 PM
ALLEGATION(S):
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Resident requires a higher level of care.
Resident left in a soaked diaper and urine saturated dressing.
INVESTIGATION FINDINGS:
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On 12/01/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent complaint visit at this facility, LPA was greeted by Assistant Administrator Reginal Jones. LPA explained the purpose of today's inspection visit was to complete the complaint investigation.

The investigation consisted of the following: An interview with the administrator, staff #2-#8 (S2-S8), resident #1-R11 (R1-R11), witness #1 (W1). A review of service records, medical records, photographs, and other pertinent documents was reviewed. A collateral visit at Asahi Residential Care and a tour of the facility on 06/02/21 and 11/30/21.

Evaluation Report continues on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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 6
Control Number 11-AS-20201210140829
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
MONTERY PARK, CA 91754
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 12/01/2021
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident requires a higher level of care.
The complainant alleges resident #1 (R1) required a higher level of care. The complainant did not provide additional details on this allegation. Records indicate that there was no lack of care or supervision with (R1’s) care. Progress notes indicate that (R1) was reassessed each time she was returned from a hospital stay and interventions included repositing and changing every 2 hours. (R1) was readmitted to the hospital on 12/11/20. and was discharged 01/16/21. Medical records indicated during (R1’s) discharge that she would require a higher level of care and that the hospital will be responsible for an appropriate placement for (R1’s) care who eventually was placed on hospice care. Interviews conducted with residents #2-#11 all revealed that have no signs of any residents that require higher-level care. According to staff #1-#8 (S1-S8) there are no residents that are being retained at this facility that require a higher level of care that would violate Title 22 Regulations 87615 Prohibited Health Conditions. The facility continues to implement employee training programs that address the nature of these issues. Based on the information gathered, there is no evidence to support the allegation mentioned above.

Allegation: Resident left in a soaked diaper and urine saturated dressing.
It is alleged resident #1 (R1) was left in a soaked diaper saturated with urine. The complainant did not provide additional information on this allegation. The administrator (S1) stated caregiver’s responsibility is to assist the residents with activities of daily living (ADL). Caregivers could be responsible for up to 10 residents at one time. When a caregiver is notified of a diaper or bedding change, the caregiver will address the matter immediately. Moreover, caregivers are trained to use aided equipment to help maneuver residents who are heavy to clean them. (S1) claims in the situation with (R1) when admitted in 2015 was medically evaluated as independent health condition declined each time she was in and out of the hospital. (S1-S2) claims that (R1) was being assisted by caregivers (R1) was being assisted with diaper changes every two (2) hours and repositioned. (S2-S8) all verified residents are monitored at least three times during each shift within the eight hours. (S2) further asserted, it would be improbable to have (R1) in soiled diapers for more than (2) two hours as she was changed every two (2) hours. Interviews with residents #2-#11 (R2-R11) all claimed they had no problems with the staff and found them to be attentive and responsive to their care and needs.

Evaluation Report continues on LIC 9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2020 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20201210140829

FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:BRAD DEHAANFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 184DATE:
12/01/2021
UNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Reggie Jones TIME COMPLETED:
04:51 PM
ALLEGATION(S):
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9
Resident has a worsening wound and pressure injury while in care.
INVESTIGATION FINDINGS:
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On 12/01/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent complaint visit at this facility, LPA was greeted by Assistant Administrator Reginal Jones. LPA explained the purpose of today's inspection visit was to complete the complaint investigation.

The investigation consisted of the following: An interview with the administrator, staff #2-#8 (S2-S8), resident #1-R11 (R1-R11), witness #1 (W1). A review of service records, medical records, photographs, and other pertinent documents was reviewed. A collateral visit at Asahi Residential Care and a tour of the facility on 06/02/21 and 11/30/21.

Evaluation Report continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20201210140829
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
MONTERY PARK, CA 91754
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 12/01/2021
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident has a worsening wound and pressure injury while in care.
It is alleged resident #1 (R1) had a worsening wound and pressure injury while in care. The complainant claims that (R1’s) wound deteriorated and developed more deep tissue injuries. According to service records and (S2) Declaration, (R1) was sent to the hospital on 11/16/20 and returned on 11/17/20. During (R1’s) stay at the hospital, she developed a Stage 1 pressure wound. Despite all interventions including reposition and diaper changes, (R1)'s wounds developed to Stage 2 while at the facility. According to (S2) the facility made attempts for Home Health assistance and was unsuccessful. According to an incident report (R1) was readmitted on 12/11/20 at the hospital for further evaluation and intervention. (S2) reports there was no wound care plan in place when the facility was treating the (R1) for Stage 1 or 2 pressure injuries. According to medical records (R1) when admitted on 12/11/20 had pressure ulcer at Stage 4. An interview with (W1) stated that he was aware that (R1) had pressure injuries and was unable to determine the stage level as it was difficult to do an in-person visit during the COVID pandemic. An interview with (R1) claims she had pressure injuries while she was being cared for at the facility and it was painful. Based on interviews and physical evidence, there is sufficient proof to support the allegation mentioned above.

Based on the Department's observation and interviews, records, and photographs reviewed, the preponderance of evidence standard has been met, therefore the allegation of "Resident has a worsening wound and pressure injury while in care" is found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

An exit interview was conducted with Reggie Jones. The Rights were discussed, and a copy of Appeals Procedures for Licensees was provided, as well as a copy of this report.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20201210140829
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
MONTERY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2021
Section Cited
CCR
87631(3)(A)
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87631 Healing Wounds (3) Residents with a stage one or two pressure injury must have the condition diagnosed by a physician or an appropriately skilled professional. (A) The resident shall receive care for the pressure injury from a physician or an appropriately skilled professional.
This requirement was not met as evidenced by:
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Licensee agrees that a Plan of Correction in place by 12/15/21. The licensee will adhere to Title 22 Section 87631 and develop a written plan. POC must be sent to licensing office by POC date 12/15/21.

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Based on LPA observations, interviews conducted and record reviews, the Licensee failed to ensure to address R1's diagnosed by skilled professional for the Stage 1&2 wounds. No wound care plan in place. This violation poses an immediate health and safety risk to residents in care.
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Type B
12/15/2021
Section Cited
CCR
87466
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87466 Observation of the Resident
State regulations require the licensee to ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
This requirement was not met as evidenced by:
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Licensee shall have a written plan to ensure that in addition to the resident's needs and services plan a specific plan is drafted for each resident's change in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. The plan must be submitted by POC date 12/15/21 to the licensing office.
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Based on LPA observations, interviews conducted, and record reviews, the Licensee was aware of R1's wounds condition and incorrectly diagnosed the wound condition. This violation poses a potential health and safety risk to residents in care.
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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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20201210140829
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
MONTERY PARK, CA 91754
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 12/01/2021
NARRATIVE
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Furthermore, (R2-R11) felt their care and supervision are being met and were complimentary of the staff.
According to (S1) the staff went above and beyond what was expected and that (R1) was not charged additional fees for the additional services performed. An interview with (R1) could not recall if she was left in soiled clothing or diapers. Based on the information gathered, there is no evidence to corroborate the allegation mentioned above.

The Department’s investigation consisted of an inspection of the facility, observation, analysis of (R1)'s service records, and interviews conducted and found no evidence to support the allegations: "Resident requires a higher level of care" and "Resident left in a soaked diaper and urine saturated dressing".

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Reggie Jones and a copy of the report was provided by email.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6