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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608029
Report Date: 10/13/2023
Date Signed: 10/17/2023 10:05:34 AM


Document Has Been Signed on 10/17/2023 10:05 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



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: 241DATE:
10/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Janie AcostaTIME COMPLETED:
03:25 PM
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On 10/13/23, Licensing Program Analyst's (LPA's) Villegas and Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA's met with Executive Director Janie Acosta as the purpose of today’s visit was explained. The facility is licensed to serve The facility is licensed to serve 300 elderly adults 60 and over non-ambulatory of which 10 may be bedridden, may retain 30 hospice residents and has a dementia Wing w/ delayed egress. Current census is 241.

The facility is a 3-story structure located in a residential neighborhood and consists of the following: 278 bedrooms and 4 common bathrooms, multimedia rooms, commercial kitchen, large dining room, media room and a large common patio.

LPA’s conducted a records review of 10 staff records, 10 resident records, and 10 medication Administration Records. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire and disaster drill was conducted on 09/08/23, fire extinguishers fully charged and observed throughout the facility, carbon monoxide detectors, smoke detectors and auditory signals are operational. Landline and internet service was observed. Liability insurance is current and active.

Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F..

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 10/13/2023
NARRATIVE
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During today’s visit the following discrepancy was cited on 809 D page.

Exit interview conducted with Executive Director Janie Acosta, appeal rights explained, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/17/2023 10:05 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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: 10/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
87465 Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as evening medication was not checked off on MAR and there was no documentation detailing if resident took or refused the prescribed medication which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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Licensee will conduct in-service on the importance of medication documentation and will send LPA a copy of in-service signed and dated by staff in attendance by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 981-1755
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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