197608029-4-19-2022-11-AS-JHAD-CEASDD-20220510134657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:36:58 PM

Unsubstantiated

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
04/15/2022 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20220415125015

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	JAMES BENDER		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS: 183	DATE:	04/19/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Reggie Jones		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff refused to take resident back into care

INVESTIGATION FINDINGS:

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On 04/19/2022 around 09:00 am 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 04/19/2022 LPA Calderon interviewed Administrator S1 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, LA Downtown Medical Center medical records, Physicians Report for R1. On 04/19/2022 LPA Calderon interviewed staff S2-S4 regarding complaint and on 04/19/2022 LPA Calderon interviewed R2-R10 for complaint. On 04/19/2022 LPA Calderon interviewed W2 for complaint and on 04/19/2022 LPA Calderon left 3 messages to interview W1 for complaint.

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: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

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-20220415125015

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: 04/19/2022

NARRATIVE

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The investigation revealed the following:

Allegation: Staff refused to take resident back into care
It is alleged on facility Staff refused to take resident back into care. On 04/19/2022 LPA Calderon interviewed W2 for complaint, W1 states that R1 is violent with staff and residents and has late stage dementia per the doctor’s information. W2 states that R1 has also been violent with her personally and W2 children and therefore R1 is in the memory care unit of the facility. W2 states that the facility called W2, and W2 took R1 to the doctor’s office for evaluation. On 04/19/2022 LPA Calderon interviewed S1 who stated that R1 was aggressive with staff and other residents and R1 was taken by R1 family to the hospital to be evaluated and medication adjusted. S1 states that the facility never refused to take R1 back, just that they needed R1 medication adjusted for dementia. On 04/19/2022 LPA Calderon interviewed S2-S4 all state that R1 had become more aggressive with female staff and residents and R1 was taken to the hospital for R1 medication to be adjusted. On 04/19/2022 LPA Interviewed R2 – R10 all residents do not live in the memory care unit, but state they have no issues with receiving transportation to and back from the doctors or hospital when needed. On 04/19/2022 LPA Calderon attempted to interview R1 who has dementia and was not able to answer any questions regarding the complaint. On 04/19/2022 LPA Calderon received and reviewed the needs and services plan, physician report, LADMC hospital report for R1. Reports support that R1 has late stage dementia and has aggressive traits due to the dementia, R1 medication was adjusted and R1 was returned to the facility. On 04/18/2022, 04/19/2022 left message for W1 to call. On 04/18/2022 LPA Calderon emailed W1 who did respond by email.

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 Administrator Reggie Jones, 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: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC9099 (FAS) - (06/04)

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