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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 10/21/2020
Date Signed: 11/02/2020 03:13:05 PM



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
06/01/2020 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200601164301
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: 212DATE:
10/21/2020
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Brad Dehaan, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility has insects.
INVESTIGATION FINDINGS:
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On 10/21/20 at 2:00 PM, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent visit in order to render investigation findings for the above allegation. Due to the situation surrounding the coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation findings was conducted telephonically with Brad DeHann, the facility administrator and the purpose of the visit was explained.
The investigation consisted of the following: On 06/10/20 Licensing Program Analyst (LPA) Martessa Brown met with Brad DeHann, the facility Administrator. LPA conducted a video call and toured the physical plant with the administrator. During the visit LPA conducted a telephone interview with the administrator and requested documentation via email: Residents #1’s most recent physician report, individual needs and service plan, admission agreement and any relevant incident reports, pest control invoices and reports within the last 6 months and house rules.
The investigation revealed the following:
9099-C is on the next page
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
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-20200601164301
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: 10/21/2020
NARRATIVE
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Regarding the allegation: Facility has insects

On 6/10/20, LPA interviewed the facility Administrator, regarding the above allegation, he stated the facility had insects 4 months ago. The residents would go to the receptionist area to complain. The last report of insect was 3 weeks. He also mentioned pest control comes every month and would routinely treat common areas inside and outside facility. He also stated R1 complained about insects and requested to be moved to another floor. Also, residents have pest control or maintenance to service her room. On 6/12/20 LPA interviewed over the phone Staff members #S1-S5 regarding the above allegation, a couple of staff stated they have seen insects in the facility recently. They also confirmed pest control comes to the facility. Housekeeping clean residents’ room every day and deep clean once a week.

LPA reviewed R1’s records regarding the above allegation, most recent physician report, individual needs and service plan and admission agreement. Pest control invoices showed they are using prevention methods once a month and follow-up visits.

On 6/11/20 and 6/12/20 LPA interviewed residents #R1- R11 over the telephone and they had reported seeing roaches in their rooms. Some of the residents confirmed they saw pest control at the facility. LPA interviewed R1 over the telphone and she stated the roaches were bad in her last bedroom and since she has moved to a different room she has been killing them herself. On 6/15//20 LPA interviewed R1 daughter and she confirmed mother has complained about insects in her room.

On 6/22/20 LPA interviewed pest control over the telephone regarding the above allegation. Technician stated they are visit the facility once a month and will do follow up visit a week later. He stated treatment is done to the interior and exterior for prevention of insects.

LIC9099-C is on the next page

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20200601164301
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: 10/21/2020
NARRATIVE
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Substantiated: Based on LPAs observations of interviews conducted with staff and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D

Exit Interview Conducted and a copy of the appeal rights given.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20200601164301
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: 10/21/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2020
Section Cited
CCR
87303(a)
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 Maintenance and Operation (a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures.
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Administrator will contact the pest control company to obtain the best course of action to treat the facility and to ensure it will be free of insects.
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This requirement is not met as evidenced by:
Based on staff & residents interviews and records review, administrator did not ensure the facility is free of insects. This poses a potential Health, Safety risk to residents in care.
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Administrator shall submit a outline treatment plan on how pest control will assist the facility to ensure facility is free from insects. Email to be sent to LPA, Martessa.brown@dss.ca.gov by 10/26/2020.
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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: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4