197608029-10-27-2020-11-AS-MVAO-BYJSTF-20210224130927

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 10/21/2020
Date Signed: 10/27/2020 01:05:46 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
06/05/2020 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200605111651

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: 212	DATE:	10/21/2020
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	BRAD DEHAAN, ADMINISTRATOR		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not provide adequate supervision resulting in resident hitting another resident in care.

INVESTIGATION FINDINGS:

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On 10/21/20 at 1:55 PM, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent visit in order to render investigation findings for the above allegation. Due to the situation surrounding the coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation findings was conducted telephonically with Brad DeHann, the facility administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 6/10/20 Licensing Program Analyst (LPA) Martessa Brown met with Brad DeHann, facility Administrator. During the visit LPA conducted a video telephone visit that consisted of viewing the physical plant inside and outside. LPA requested copies of resident’s records R1 and R2, medical records, incidents reports and facility files. LPA conducted interview with administrator.

The investigation revealed the following:

9099-C is on the next page

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

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 4

Control Number 11-AS-20200605111651

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: 10/21/2020

NARRATIVE

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Allegation: Staff did not provide adequate supervision resulting in resident hitting another resident in care.

LPA interviewed Brad and Sidonia Administrators over the telephone, on 6/10/20 and 6/11/20 regarding the above allegation. Both administrators stated resident’s R1 and R2 were roommates and both have dementia. They stated residents were in an altercation in their room. There were no witnesses during the time of incident. Administrators state R1 was struck in head with a broom by R2 ,as a result and sustained an injury to her head. Staff called 911 and resident R1 was taken to emergency. R2 was taken to the hospital later by daughter for an evaluation. They also stated the residents did not have any prior incidents with each other.

The facility failed to notice the metal broom was in residents’ room. Administrator stated he was unaware of the broom and should have not been in there. Staff was also unaware of the broom being in the room.

On 6/12/20 LPA interviewed staff members #S1-S4 regarding the above allegation over the telephone, staff indicated R1 and R2 had an altercation in their room. Staff stated call was made to 911 due to R1 sustaining a head injury. Also, stated there were no staff members around when the altercation had taken place. Staff stated there has been no prior incident between both residents.

On 6/15/20 LPA interviewed Residents #R3-R9 over the telephone regarding the above allegation. A couple of residents stated they were aware of the incident that took place but did not witness.

LPA was unable to interview R1 and R2 due to their mental capacity.

Continuation LIC9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20200605111651

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: 10/21/2020

NARRATIVE

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On 6/16/20 LPA interviewed R2’s daughter and she indicated mother had been roommates with R1 for a couple of days before incident had occur. They did not have any prior incidents. She was notified by the administrator that her mother had been in an altercation with roommate. She also was unaware of a broom being in the room. She later took her mother to emergency to be evaluated.

On 6/26/20 LPA interviewed R1’s Public Guardian over the telephone regarding the above allegation. She stated facility had called her regarding the resident’s altercation. LPA asked did R1 have any prior problems at past facility’s? She stated R1 had problems with residents at her prior facility’s.

Substantiated: Based on LPAs observations of interviews conducted with administrators, staff, residents, primary guardians and the records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D.

Exit Interview Conducted and a copy of the appeal rights given.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20200605111651

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/21/2020 Section Cited CCR 82205(F)(1)	1 2 3 4 5 6 7	Care of Person with Dementia (f)(1) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).	1 2 3 4 5 6 7	Administrator is always to keep objects locked away to ensure safety of residents. Administrator will review law section and train staff on the procedures in section 82205(F)(1).
	8 9 10 11 12 13 14	This requirement is not not met as evidenced by: Based on staff interviews and residents records, administrator did not ensure objects were inaccessible to residents in care. This is an immediate Health, Safety risk to residents in care.	8 9 10 11 12 13 14	Facility to submit proof of training to LPA's attention via email by 10/22/2020.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

LIC9099 (FAS) - (06/04)

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