197608029-6-10-2023-11-AS-EMAZ-CUX5G4-20230821195606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 04/13/2023
Date Signed: 06/10/2023 01:49:57 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
11/07/2022 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20221107084404

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	REGGIE JONES		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS: 231	DATE:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	ADMINISTRAOR JANIE ACOSTA		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility etaff failed to feed resident.
Facility not supervising resident while in care.
Facility staff failed to clean residents linens.
Facility staff lock resident in room.

INVESTIGATION FINDINGS:

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This report supersedes the report dated 04/13/2023 for clarifying the circumstances for the allegations. Although this report supersedes the previous report the complaint investigation findings remain the same: Unsubstantiated
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the Vista Del Mar Senior Living facility on 04/13/2023 and was greeted by Administrator Janie Acosta (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.
During this investigation Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10-day visit on 11/14/2022. LPA Calderon interviewed A1, W2, S2-S7, R1-R10. These interviews were conducted on 11/09/2022, 11/14/2022 and on 04/13/2023. On 11/09/2022 LPA Calderon interviewed W1-W2 for complaint. On 11/15/2022 LPA Calderon requested copies of the following: Staff and Resident rosters, Needs and Service Plan, Physician Report, Medication Administration Record (MAR), incontinence records and training, Hospice and home health care records, video or color pictures and email between W1 and facility for R1.

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: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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 4

Control Number 11-AS-20221107084404

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: 04/13/2023

NARRATIVE

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The investigation revealed the following:

Allegation #1: Facility staff failed to feed resident.

It is alleged Resident R1 was not fed by facility. On 11/14/2022 LPA Calderon interviewed A1 for complaint. A1 reported staff would assist R1 with 3 meals daily. A1 relays that R1 was able to eat in the dining room. If R1 could not make the trip to the dining room due to health, staff would deliver meals to R1. On 11/14/2022 LPA Calderon interviewed S2-S7 for complaint. S2 relays that S2 worked 5 days per week with R1. S2 relays that R1 was capable of walking to the dinning room every day for meals with support from staff. S2 relays that facility staff provide R1 with 3 meals per day and noted that hospice staff would also ensure R1 ate meals. On 11/15/2022 LPA Calderon reviewed physician report for R1. Report relays that R1 had a special diet due to health conditions and able to eat meals independently. Staff S3-S7 reported staff were aware of R1’s dietary considerations. On 04/13/2023 LPA Calderon interviewed R2-R10 regarding complaint. R2-R10 relay that the facility serve 3 meals per day and provide meal plans for those with special diets. R2-R10 relay that staff deliver food to residents who are unable to eat meals in the facility dining room.

Allegation #2: Facility not supervising resident while in care.

It is alleged that facility staffing is insufficient and R1 was left unsupervised while in care. On 11/14/2022 LPA Calderon interviewed A1 for complaint. A1 relays that facility supported R1 needs. A1 relays that the facility maintains sufficient staffing to provide the residents with needed supervision. Staff S2 relays that R1’s medical and care needs were supported by facility staff. Staff S3-S7 relay that R1 had health issues and there was a sufficient number of staff to support R1’s service plan. Staff S3 relayed that there are 3 supervisors working on the floor and 2 staff for each resident during the day. S5 relayed that there is sufficient staff to serve residents in care. On 11/15/2022 LPA Calderon reviewed R1 physician report, needs and service plan, preplacement plan, and hospice care plan. LPA found R1 did have serious health conditions. On 04/13/2023, LPA Calderon interviewed R2-R10 for complaint. Residents R2-R10 did not express concerns with staffing or needs not being met. R2-R10 relayed that there are many new staff, but that staff do care of resident’s needs.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 11-AS-20221107084404

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: 04/13/2023

NARRATIVE

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Allegation #3: Facility staff failed to clean residents’ linens.

The alleged facility staff failed to clean residents’ linens. On 11/14/2022 LPA Calderon interviewed A1 for complaint. A1 relays that R1 had health issues and had incontinence issues. A1 relays that staff assisted R1 with hygiene 2 to 3 times per day or when needed. Staff changed R1’s bed linens daily or and as needed. On 11/14/2022 LPA Calderon interviewed S2-S7 for complaint. S5 and S7 relayed that R1 was assisted with hygiene needs 2 to 3 times per day and bedding was changed daily. On 11/15/2022 LPA Calderon reviewed physician report, pre-placement, and hospice records for R1. On 04/13/2023 LPA Calderon interviewed R2-R10 for complaint. Residents R2-R10 report staff clean their rooms and change bedding one time per week or as needed.

Allegation #4: Faculty staff locked resident in room.

It is alleged that facility staff locked R1 in R1’s room. On 11/14/2022 LPA Calderon interviewed A1 for complaint. A1 relays that resident would wander due to health issues. A1 states that residents do leave their rooms and wander the hallways. A1 relays that the unit R1 resides in has security to prevent resident from leaving the unit unattended. A1 relays that there are no situations that support any staff locking a resident in their room. A1 relays that resident doors can be secured, but residents are able to leave their rooms freely and staff are able to enter rooms. Staff S2-S7 reported that R1 required assistance transferring from R1’s bed to R1’s wheelchair. Resident R1 was not able to leave R1’s room without assistance from staff. Staff S2-S7 reported residents are not locked inside their rooms. On 11/15/2022, LPA Calderon reviewed hospice records R1’s that indicate R1 is non-ambulatory and requires assistance to transfer. On 04/13/2023, LPA Calderon interviewed R2-R10 for complaint. Residents R2-R10 reported their room doors are not locked by staff.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20221107084404

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: 04/13/2023

NARRATIVE

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Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “Facility staff failed to feed resident” “Facility not supervising resident while in care” “Facility staff failed to clean resident linens” “Facility staff lock resident in room” is found to be UNSUBSTANTIATED.

An exit interview was conducted and copy of the Complaint Report was provided to the Administrator (A1).

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

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