197608029-4-26-2023-11-AS-EMAZ-CRJUB6-20230505152549

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 04/26/2023
Date Signed: 04/26/2023 03:12:52 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
03/10/2023 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20230310124102

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	JANIE ACOSTA		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS: 231	DATE:	04/26/2023
		UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	ADMINISTRATOR JANIE ACOSTA		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff did not safeguard resident's medications
Facility staff did not give resident's medication as prescribed
Facility elevator does not operate properly
Facility elevator permit expired

INVESTIGATION FINDINGS:

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On 04/26/2023 around 09:00 am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA met with Administrator Janie Acosta and the purpose of the visit was explained.

The investigation revealed the following:

Allegation 1: Facility staff did not safeguard residents’ medications.

It is alleged that facility staff did not safeguard residents’ medications. During this investigation, LPA Calderon interviewed R1-R7, A1, S2-S6, W1-W3. These interviews were conducted on 3/13/2023, 3/15/2023 and 04/26/2015. LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, Medication administration records (MARS), Physicians Report for R1 and elevator service records.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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 5

Control Number 11-AS-20230310124102

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 04/26/2023

NARRATIVE

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On 03/13/2023 LPA Calderon interviewed W1 for complaint. W1 states that staff lost or misplaced R1 medications. W1 states that R1 went with W1 to W1 home and staff did not provide medications for trip. W1 states that staff could not find or locate R1 medications and pills went missing or were lost. On 03/15/2023 LPA Calderon interviewed A1 for complain. A1 states that R1 medications were not lost, misplaced, or stolen. A1 states that all R1 pills were accounted for and W1 was given the right amount pills for the visit to W1 home. On 03/15/2023 LPA Calderon interviewed S2-S6 for complaint. S2-S6 was unaware of any medications being lost, stolen or misplaced. S2-S6 was not aware of any call or conversations with W1 or R1 regarding lost pills. On 04/26/2023 LPA Calderon interviewed R1-R7 for complaint. R1 states that R1 spent some time at W1 home and pills were missing from R1 bottle. R1 states that staff was able to account for all pills and was able to give W1 all medications R1 would need while away from the facility. R3, R5, R6, R7 state that they take their own medications and have a lock box. Residents state that staff keeps records of resident medications and no medications have been lost, misplaced, or stolen. On 03/15/2023 LPA Calderon reviewed the MAR for R1. MAR records suggest that all medication pills were accounted for, and staff safeguard residents’ medications. On 04/26/2023 LPA Calderon interviewed W2-W3 for complaint. W1-W2 have no knowledge of any of their family members medication that went missing, lost, or stolen.

Allegation 2: Facility staff did not give residents medication as prescribed.

During this investigation, LPA Calderon interviewed R1-R7, A1, S2-S6, W1-W3. These interviews were conducted on 3/13/2023, 3/15/2023 and 04/26/2015. LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, Medication administration records (MARS), Physicians Report for R1 and elevator service records.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 11-AS-20230310124102

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 04/26/2023

NARRATIVE

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It is alleged that facility staff did not give residents medication as prescribed. On 03/13/2023 LPA Calderon interviewed W1 for complaint. W1 states that staff could not give medications to R1 as R1 was not in the facility and at W1 home. W1 requested copies of R1 MAR and facility paperwork showed that staff had marked medications as given and prescribed. W1 states that this was not possible was R1 was at W1 home when supposed medication was being given to R1. On 03/15/2023 LPA Calderon interviewed A1 for complaint. A1 states that staff would not alter, or fake medication reports and that staff give all residents medications as prescribed by a doctor’s office. On 03/15/2023 LPA Calderon interviewed S2-S7 for complaint. S2 and S4 both had conversations with W1 and R1 regarding the prescribed medications and explained to W1 and R1 how the MAR was documented by staff and that there is no way to alter or change the medications that are given. S2-S5 state that they were not aware of any changes to R1 prescribed medications and that all medications were noted and documented when given. On 04/26/2023 LPA Calderon interviewed R1-R7 for complaint. R3, R5, R6 state that they self-medicate and the medication they take is prescribed and staff keeps records of every pill that residents take. On 04/26/2023 LPA Calderon interviewed W2-W3, both witness state that staff only give medications prescribed. On 03/15/2023 LPA Calderon reviewed the MAR for R1. R1 MAR review suggest that no medications were missing, and all pills were accounted for.

Allegation 3: Facility elevator does not operate properly.

During this investigation, LPA Calderon interviewed R1-R7, A1, S2-S6, W1-W3. These interviews were conducted on 3/13/2023, 3/15/2023 and 04/26/2015. LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, Medication administration records (MARS), Physicians Report for R1 and elevator service records.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20230310124102

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 04/26/2023

NARRATIVE

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It is alleged that facility elevator does not operate properly. On 03/13/2023 LPA Calderon interviewed W1 for complaint. W1 states that R1 and W1 were inside the elevator and the elevator stopped moving. W1 states that the elevator moved to the second floor and the doors opened. W1 states that they were stuck inside the elevator for a few minutes. On 03/15/2023 LPA Calderon interviewed A1 who states that elevator 1 has had service come to work on the mechanics and A1 was not aware that any person was stuck inside the elevator for a period. A1 states that if the elevator stops working the system moves the elevator to the closest floor and the doors open. If this does not work, then there is phone to call 911. On 03/15/2023 LPA Calderon interviewed S6 who states that the elevator company services the facility elevators monthly and S6 is not aware of any person being stuck inside the elevator for any period. On 04/26/2023 LPA Calderon interviewed R1-R7 for complaint. R2, R4, and R7 state that the elevator is slow and is down for service. Resident state that they have never been stuck inside the elevator. R1, R3, R5 and R6 state that they have never been stuck inside the elevator. On 04/26/2023 LPA Calderon interviewed W2-W3 for complaint. W2-W3 state that the main elevator work every time and they have never been stuck inside the elevator. On 03/15/2023 LPA Calderon reviewed elevator service records; no issues were noted.

Allegation 4: Facility elevator permit expired.

During this investigation, LPA Calderon interviewed R1-R7, A1, S2-S6, W1-W3. These interviews were conducted on 3/13/2023, 3/15/2023 and 04/26/2015. LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, Medication administration records (MARS), Physicians Report for R1 and elevator service records.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20230310124102

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 04/26/2023

NARRATIVE

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It is alleged that facility elevator permits expired. On 03/13/2023 LPA Calderon interviewed W1 for complaint. W1 states that W1 was inside the elevator and noted that the elevator permit had expired. On 03/15/2023 LPA Calderon toured the facility with A1 and walked into elevator 1 and 2 and noted that the elevator permit had expired. A1 states that the state is behind in providing new permits, but they are in the process of getting new permits. On 03/15/2023 LPA Calderon interviewed S6 who states that the elevator is serviced monthly or when need and they are in the process of getting new permits. On 03/15/2023 LPA Calderon reviewed letter from the department of industrial relations Elevator Unit dated 03/15/2023, elevator #086749077001, this application is complete and is being processed.

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 face-to-face meeting was conducted with Administrator Janie Acosta, and a hard copy was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

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