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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 04/13/2023
Date Signed: 06/10/2023 01:28:52 PM

Substantiated


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
04/11/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230411163806
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:JANIE ACOSTAFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 231DATE:
04/13/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:ADMINISTRATOR JANIE ACOSTATIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff did not safeguard resident's personal belongings
INVESTIGATION FINDINGS:
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This report supersedes the report generated on 04/23/2023 for clarifying the circumstances for the allegation. Although this report supersedes the previous report complaint investigation findings remain the same: Substantiated
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 the investigation, Licensing Program Analyst (LPA) Jose Calderon interviewed A1, S2-S4, R1-R7. These interviews were conducted on 04/12/2023. On 04/12/2023 LPA Calderon requested copies of the following: Staff and Resident rosters, Needs and Service Plan, Physician Report, Medication Administration Record (MAR), Medication Release Form for R1.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (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 6
Control Number 11-AS-20230411163806
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 did not safeguard residents’ personal belongings.

On 04/12/2023 LPA Calderon interviewed R1 for complaint. R1 relays that R1 had purchased two packages and have them mailed to the facility. R1 relays that the front deck staff signed for the two packages and then lost one of R1 packages. R1 relays that the “green” mail card was signed by staff and R1 has proof. R1 does not know what happened to R1 package only that it was stolen or lost. On 04/12/2023 LPA Calderon interviewed S2 for complaint. S2 relays that S2 noted that a front desk employee had signed for the packages and R1 had shown S2 the “green” mail card with the staff signature. S2 relays that S2 asked front desk staff to follow up on the missing package, but no staff followed up and the package was lost and S2 did not follow up on the lost package. On 04/12/2023 LPA Calderon interviewed A1 for complaint. A1 relays A1 was not aware of the missing package and that the facility will replace the lost item or pay the R1 for the cost of the lost package.

Based on LPA Calderon observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegations “facility staff did not safeguard residents’ personal belongings” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are being cited on the attached LIC 9099D.

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator Janie Acosta (A1).

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (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: 6 of 6
Control Number 11-AS-20230411163806
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: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited
CCR
85072(b)(6)
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85072 Personal Rights (b) The licensee shall insure that each client is accorded the following personal rights.(6) To possess and use his/her own personal items, including his/her own toilet articles. This requirement was not met as evidenced by



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Administrator will provide training from front desk clerks on how to sign for and secure residents packages by the due date of 04/21/2023
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Based on records reviewed and interviews conducted the licensee failed to ensure the safeguard of residents personal belongings. This poses a Safety risk to residents in care.
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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: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
04/11/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230411163806

FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:JANIE ACOSTAFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 231DATE:
04/13/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:ADMINISTRATOR JANIE ACOSTATIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
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9
Facility staff did not safeguard resident's medications
Facility staff do not provide a safe environment for resident in care
INVESTIGATION FINDINGS:
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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 the investigation, Licensing Program Analyst (LPA) Jose Calderon interviewed A1, S2-S4, R1-R7. These interviews were conducted on 04/12/2023. On 04/12/2023 LPA Calderon requested copies of the following: Staff and Resident rosters, Needs and Service Plan, Physician Report, Medication Administration Record (MAR), Medication Release Form for R1.

The investigation revealed the following:

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (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: 4 of 6
Control Number 11-AS-20230411163806
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 #1: Facility staff did not safeguard residents’ medications.

On 04/12/2023 LPA Jose Calderon interviewed A1 for complaint. A1 reported, R1 is administering medications independently as of 01/23. A1 relays that the facility Medication Administration Records, dated 09/22 to 01/23, support that R1’s medications were administered per physicians’ orders. A1 relays that A1 was not informed of R1 missing inhalers or medication. 04/12/2023 LPA Calderon interviewed R1 for complaint. R1 relays that when R1 moved into the facility 2 inhalers had gone missing. R1 relays that due to the two missing inhalers, R1 began storing and administering medication independently. Resident R1 reports, medications are now stored in a locked box supplied by the facility and has no issues with missing medication since 2022. On 04/12/2023 LPA Calderon interviewed S2-S4 for complaint. Staff S4 relays that R1 is storing and taking medications independently. Staff S4 trained R1 to administer medications independently. Staff S4 reports monitoring R1 to ensure R1’s medications are being taken daily. Staff S4 relays that the facility administered R1’s medications from 09/22-01/23 and records support that R1 was given medications needed. On 04/12/2023 LPA Calderon interviewed R2-R7 for complaint. R3 and R5 handle their own medications. R3 and R5 relay that they have not experienced staff mishandling their medications. Resident R2, R4, R6 and R7 relays that they have not experienced issues with missing or stolen medications. On 04/12/2023 LPA Calderon reviewed the Medication Administration Record (MAR) for R1 for 11/22-12/22. LPA Calderon found records indicate R1 received 2 inhalers.

Allegation #2: Facility staff do not provide a safe environment for residents in care.

On 04/12/2023 LPA Calderon interviewed R1 for complaint. R1 relays that R1 does not feel safe living in this facility due to staff entering R1 room. R1 reports locking R1’s room door and “does not like staff coming and going” inside R1’s room. R1 reports residing in a shared room and has a roommate. On 04/12/2023 LPA Calderon interviewed A1 for complaint. A1 relays that A1 did not know that R1 did not feel safe with staff entering R1’s room. A1 relays that staff do provide assistance to R1’s roommate who is sight impaired. A1 relays that staff do secure R1’s room door when they exit. On 04/12/2023 LPA Calderon interviewed S2-S4 for complaint. S2-S4 reported that staff enter R1’s room to clean and to provide assistance to R1’s roommate. S2-S4 relays that when exiting R1’s room R1’s door is secured. On 04/12/2023 LPA Calderon interviewed R2-R7 for complaint. R2-R7 reported they feel safe living in the facility and expressed no issues or concerns with staff.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (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 6
Control Number 11-AS-20230411163806
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 did not safeguard residents’ medications” “Facility staff do not provide a safe environment for resident in care “is found to be UNSUBSTANTIATED.

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

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (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: 2 of 6