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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 04/18/2022
Date Signed: 04/18/2022 04:29:34 PM

Substantiated


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
12/14/2020 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20201214150519
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: 188DATE:
04/18/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:James Bender, Vice PresidentTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident sustained a fracture while in care
Facility failed seek timely medical attention
Facility has insects
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with James Bender, the facility Vice President.

The investigation consisted of following: Interviews and Record reviews. IB investigator Dennis Douglas investigated for allegations 1 & 2. On 02/15/20, LPA Soto interviewed via telephone Executive Director Brad Dehaan for allegation 3. LPA Soto received the following documents on 12/15/20: Resident Roster, Staff Schedule, Face sheet (ID/Emergency contact), Physician’s Report, Admissions Agreement, and Pre-Appraisal.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
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-20201214150519
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: 04/18/2022
NARRATIVE
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Based on IB investigation; it was revealed that R1 alleged R1 was dropped on the floor by staff members, S1 & S2 as they attempted to lift R1 from R1’s wheelchair. During the investigation, R1 was interviewed by CCL/IB (Community Care Licensing Investigation Branch) investigator and R1 disclosed that staff members S1 & S2 attempted to pick R1 up after they observed R1 on the floor next to R1 bed. R1 stated R1 was on the floor because R1 decided to execute what R1 called a "controlled slide" out of R1’s bed. R1 explained that S1 picked R1 up by R1’s legs, while S2 picked R1 up by R1’s hands. R1 stated R1 slipped out of S2 hands causing R1 to fall on the floor. As a result, R1 injured his shoulder. R1 advised S1 and S2 that they injured R1’s shoulder, but they claimed R1 injured R1’s shoulder by falling out of R1’s bed. R1 was adamant that R1 did not "fall" out of R1’s bed. R1 "slid" out of R1’s bed, which did not result in injuring R1 shoulder. During the investigation, it was revealed that R1 had informed several different sources (a family friend, hospital staff, and additional staff members at the facility) that it was facility staff that caused R1 injury. Both S2 & S1 deny dropping R1 but acknowledged attempting to pick R1 up off the floor but was unable to because R1 was too heavy. Per the medical records, it indicated R1 indeed sustained a "Mildly Displaced Fracture of the Proximal Humerus Extending to the Greater Tuberosity." It appears more likely than not that the injury sustained to R1’s shoulder was the result of R1 being dropped by facility staff. Therefore, the Allegation 1 – resident sustained a fracture while in care is "substantiated" at this time.

Allegation # 2 – Facility failed to seek timely medical attention – During IB investigation; it was revealed that R1 alleged R1 was dropped on the floor by staff members, S1 & S2 as they attempted to lift R1 from R1’s wheelchair. During the investigation, R1 was interviewed by CCL/IB (Community Care Licensing Investigation Branch) investigator and R1 disclosed that staff members S1 & S2 attempted to pick R1 up after they observed R1 on the floor next to R1 bed. After the incident R1 complained of pain in R1's shoulder, staff only provided pain medication. Staff did not send R1 immediately after incident, staff waited several days after incident to send R1 to the ER only after R1 insisted on being sent to the ER Therefore, the allegation is substantiated.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20201214150519
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: 04/18/2022
NARRATIVE
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Allegation 3 – facility has insects. The Interview conducted with Executive Director, he stated that the facility did have cockroaches in the facility. Orkin pest control came to spray the facility on the 3 following dates: 09/02/20, 11/17/20, & 12/04/20. LPA reviewed Orkin pest Control invoices for those dates. The cockroaches had been eliminated from the facility. Therefore, the allegation is substantiated.

Based on Investigator Douglas observations and interviews which were conducted and records reviewed, violations were found and are being cited on the attached LIC 809D per Title 22, Division 6, Chapter 8 of the California Code of Regulations; and an immediate Civil Penalty in the amount of $500.00 issued, although an enhanced civil penalty is being considered.


According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued citations.

An exit interview was conducted with James Bender, Vice President and a hard copy of report was provided along with Appeal Rights.



SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20201214150519
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: 04/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/22/2022
Section Cited
CCR
87468.1(a)(3)
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87468.1 (a)(3)
To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This was not met as evidenced by
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Executive Director implement a plan of training for all staff. What types of training will be taught, when, and who will perform the trainings? Send to LPA on or before POC due date
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Based on observations and interviews Staff dropping R1 and fracturing his shoulder. Which poses a potential health and safety risk to persons in care.
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Deficiency Dismissed
Type A
04/22/2022
Section Cited
CCR
87465(g)
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87465(g) -The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).this was not met as evdenced by:
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Executive Director implement a plan of training for all staff. What types of training will be taught, when, and who will perform the trainings? Send to LPA on or before POC due date
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Based on observations and interviews staff did not call or take R1 to the ER in a timely manner. Which poses a potential health and safety risk for persons 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20201214150519
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: 04/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
04/22/2022
Section Cited
CCR
87303(a)
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87303(a) 873039a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidence by:
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Executive Director will implement a plan on best practices to ensure the facility will not have a pest problem in the future. Send to LPA on or before POC due date.

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Based on observations and interviews Facility had roaches, which poses a potential health and safety risk for the persons in care.
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Deficiency Dismissed
Type B
04/22/2022
Section Cited
CCR
87405(h)(5)
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87405(h)(5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified in the residents' Pre-Admission Appraisals, specified in Section 87457, Pre-admission Appraisal, and Reappraisal, as specified in Section 87463.
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Administrator will create a plan and how to report and seek immediate help for residents by POC due date.
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This was not met as evidence by: Based on observations and interviews Administrator failed to get immediate help for R#1. Which poses a potential health and safety risk for persons 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5