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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 05/01/2023
Date Signed: 05/01/2023 04:49:07 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
08/05/2020 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200805114021
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: 230DATE:
05/01/2023
UNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Janie Aosta-AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident sustained pressure ulcers while in care
Staff did not change residents soiled diaper in a timely manner
Unlawful eviction
INVESTIGATION FINDINGS:
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On 5/1/22023, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent visit in order to render investigation findings for the above allegation. LPA Brown met with the facility administrator Janie Aosta-Administrator the purpose of the visit was explained.

The investigation consisted of the following: On 8/7/2020, Licensing Program Analyst (LPA’s) Martessa Brown and Janae Hammond conducted a 10-day complaint tele-visit and met the Administrator Brad Dehann. LPA requested the following documentations: Staff and Resident Roster, admission agreement, residents (R1’s) file: Emergency Identification, Physicians Report, Needs and Service, Incontinent care plan, Medication records for the last 6 months, hospital records, staff training records and recent incident reports. The complaint was referred to Community Care Licensing Investigations Branch and assigned to Special
Investigator Denis Seng. Investigator interviewed 2 witnesses, Residents R1-R3, Administrator Brad Dehann and staff members S1-S5. Reviewed and obtained Resident R1’s Kaiser Medical records.
The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
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 8
Control Number 11-AS-20200805114021
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: 05/01/2023
NARRATIVE
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Regarding the allegation #1: Resident sustained pressure ulcers while in care

It was alleged that the Resident (R1) was diagnosed with stage IV pressure injuries on the left and right buttocks while living at the facility. On 6/25/2020 and 9/3/2020, investigator conducted interviews with administrator and staff members S1-S5 regarding R1’s pressure injuries. On 6/25/2020, S1-S5 stated resident was placed on incontinent care and was found with 2 small red sores on the lower left and right buttocks. Investigator reviewed the records and notes instructed staff to change R1 every 2 hours. On 9/3/2020, interview conducted with witness (W1) confirmed R1 to wear adult diapers on 6/25/2020. On 10/13/2020, Investigator conducted an interview with R1, and resident was unable to recall any details. Interviews conducted with S1-S5, confirmed with the Investigator R1 diapers was changed every 2 hours. Kaiser Medical records revealed on 6/27/2020, R1 had a stage 2 pressure injuries ulcer on the bilateral gluteus. On 7/9/2020 Kaiser noted a stage 3 pressure injuries on the left and right buttocks. Based on interviews and records review, R1 did not sustain a stage 3 or 4 pressure injuries while living at the facility. The above allegation is found to be unsubstantiated.

Regarding Allegation: Staff did not change residents soiled diaper in a timely manner

It was alleged that resident was sitting in diapers for an extended period. On 10/5/2020, LPA conducted interviews with Residents (R1-R6). During interviews conducted, 6 residents stated they have no concerns with their diapers being change. Residents stated staff will change them every 2-3 hours and will call staff if needed to be change earlier and staff will assist. LPA conducted interviews with the Brad Dehann- Administrator, Sidonia Cordis- Resident Care Director and staff members S1-S7 regarding the above allegation. Administrator, Resident Care Director and S1-S7, stated residents that are incontinent are change every 2-3 hours. LPA reviewed R1’s Changing Log and dates that stated R1 was changed every 2 hours and

Regarding Allegation: Unlawful eviction

It was alleged that resident was evicted unlawful. Interviews conducted with the Administrator, Resident Care Director and residents S1-S7. On 10/5/2020 Administrator stated Resident Care Director stated R1 had went to the hospital on 6/27/2020. Administrator and Resident Care Director stated resident was able to come back to the facility once R was released from the hospital. R1 was unable to return to facility due to needing higher level of care. Residents Interviews conducted with S1-S7, did not hear of any unlawful eviction with any residents. LPA reviewed records and R1 was in the hospital and transferred to a skill nursing facility on 7/15/23. Resident still had belongings in the facility with the anticipation of returning but resident was unable to return to the facility. Resident was not evicted from the facility.

Continuation LIC 9099 is on the next page.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
08/05/2020 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200805114021

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: 230DATE:
05/01/2023
UNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Janie Aosta-AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaging residents medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/1/22023, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent visit in order to render investigation findings for the above allegation. LPA Brown met with the facility administrator Janie Aosta-Administrator the purpose of the visit was explained.
The investigation consisted of the following: On 8/7/2020, Licensing Program Analyst (LPA’s) Martessa Brown and Janae Hammond conducted a 10-day complaint tele-visit and met the Administrator Brad Dehann. LPA requested the following documentations: Staff and Resident Roster, admission agreement, residents (R1’s) file: Emergency Identification, Physicians Report, Needs and Service, Incontinent care plan, Medication records for the last 6 months, hospital records, staff training records and recent incident reports. The complaint was referred to Community Care Licensing Investigations Branch and assigned to Special Investigator Denis Seng. Investigator interviewed 2 witnesses, Residents R1-R3, Administrator Brad Dehann and staff members S1-S5. Reviewed and obtained Resident R1’s Kaiser Medical records.
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
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 8
Control Number 11-AS-20200805114021
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: 05/01/2023
NARRATIVE
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 Regarding the allegation #2: Staff mismanaging residents’ medication.

It was alleged that staff wanted to increase the resident’s medication. On 6/22/2020, medical records revealed that doctor had order an increase in R1’s medication Seroquel (Quetiapine) from 25mg to 1.5 tablets 3 times a day and then reevaluate. Medication order was schedule to start 6/22/20-7/15/20. On 6/25/2020 and 9/23/2020, Investigator conducted interviews with Administrator and Staff members, S1-S5. Staff members stated R1’s behavior was aggressive and was hard to monitor resident in the facility. Staff stated R1 would leave isolation room instead of quarantine and would wander the facility and jeopardize other residents. Staff stated R1 would be redirected but will be combative. Staff stated was aware of medication increase and was directed to check resident every 2 hours. Interviews and documents revealed the following: On 6/16/2020, records showed that, R1 tested positive for Covid-19. On 6/16/2020, a meeting was held by telephone with administrator and witnesses (W1 and W2) to discuss R1’s care plan, due to behavior changes. During meeting conversation administrator, W1 and W2 have all agreed to increase R1’s medication. On 6/16/2020, medical record notes from physician were documented that W2 stated R1 is being combative and having a hard time in isolation. Administrator, W1 and W2, have agreed to increase medication. On 6/21/2020, it was noted that R1 would leave the isolation room and wander. On 6/21/20, incident took place that R1 left the isolation room through a sliding glass door on the balcony. R1 entered a neighboring resident's room and had wandered into the hallway. On 6/22/2020, staff was notified of changes to increase medication. LPA reviewed R1 medication records for the month of June 2020. Investigation revealed that on 6/25/20-6/26/20 the medication Quetiapine was on hold for 2 days and not given to R1. LPA did not see any directives to hold medication from R1.


Based on records review and interviews, it was determined that R1’s medication was mismanaged, and the above allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator, and a hard copy was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20200805114021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/02/2023
Section Cited
CCR
87468/1(a)(2)
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87468.1
Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2)( To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidence by:
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Administrator with review regulation and retrain staff on medication by POC due date 5/2/23.
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LPA reviewed R1 medication Mars and on 6/24/2020 and 6/25/2020 Medication Mars Quetiapine was on hold

This posses an immediate health and safety issue.
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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: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20200805114021
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: 05/01/2023
NARRATIVE
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Facility did not provide resident a refund

It was alleged facility did not provide resident a refund. LPA conducted interview with (W1) stated the facility was to provide a refund due to R1 not living at the facility. Interview conducted with Administrator stated spoke to (W2) requested to have resident discharge from Vista Del Mar and not returning. LPA reviewed records and R1 belonging was moved out on 8/2/2020 and on 8/07/2020, refund was process.

Exit interview conducted a copy of the report was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8