197608029-8-25-2023-11-AS-UCOL-CXDP5L-20231108100055

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 08/25/2023
Date Signed: 08/25/2023 02:43:44 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
08/23/2023 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 11-AS-20230823125050

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	JANIE ACOSTA		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS: 237	DATE:	08/25/2023
		UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Sidonia Cordis		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff are not addressing bed bug infestation.

INVESTIGATION FINDINGS:

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On 08/25/2023 Licensing Program Analyst (LPA), Antonine Richard conducted the 10 day complaint investigation visit regarding the allegation above. LPA spoke to Resident Care Director Cordis Sidonia regarding the above allegation. Later LPA was joined with Executive Director Acosta, Janie.

The investigation consisted of the following: LPA Richard toured the facility grounds with Resident Care Director Sidonia and Executive Director Acosta. LPA toured the residents' bedrooms R301, R302, R303, R304, R321, and spoke to the residents regarding the allegations. LPA requested resident R1-R2 records. Residents roster, Staff roster. Service agreement, invoices and bed bug treatment from the last two months.

In regards to the allegation Facility staff are not addressing bed bug infestation, based on records reviewed, observation, interviews conducted and information gathered there has not been a bed bugs infestation for over a year now in resident R1. LPA Richard, Resident Care Director Cordis, and resident R1, flipped the mattresses around, there were no bed bugs observed in resident R305 at the time of visit.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230823125050

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: 08/25/2023

NARRATIVE

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Allegation:
Facility staff are not addressing bed bug infestation.

On 08/25/2023, LPA Richard Reviewed records received: On 08/21/2023, Pest control had sprayed resident room R303 and resident had to leave the room for 4 hours. LPA also conducted records reviews of R1-R2 record (Needs and service Plan, Pre-Placement Appraisal, and Physician's Report for Residential Care Facility For The Elderly.) (RCFE). and resident deep cleaning schedule. R1-R2 #303 is schedule for Thursday, August 31, 2023. LPA reviewed R1 emergency visit on 08/19/2023, the Nurse stated R1 visit reason: Bite or Sting, no mention of bed bug on the report.

Based on LPA observations, interviews and records reviewed which were conducted. Although the allegation may have happened or valid the preponderance of evidence standard has not been met, therefore the above allegation is found to be Unsubstantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 .

An exit interview was conducted and a copy of the report was provided to the Executive Director Acosta Janie.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

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