197608029-12-15-2023-11-AS-MVAO-CZD23B-20240110160205

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 12/14/2023
Date Signed: 12/15/2023 08:09:40 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/20/2023 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20231120195648

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: 243	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director Janie Acosta		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Resident burned another resident with a cigarette.

INVESTIGATION FINDINGS:

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On 12/14/23 at 9:00am, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit to render investigation finding. LPA met with Executive director (ED) Janie Acosta and the purpose of today’s visit was explained.

The investigation consisted of the following: On 11/30 /23 LPA interviewed Executive Director (ED), staff #1-8 (S1-S8), witness #1 (W1), and interviewed residents # 2-11 (R2-R11). LPA obtained copies of the following for R1 and R3, face sheet, emergency Identification form, service plan, physicians report, physicians orders and preplacement appraisal information.

The investigation revealed the following:
Allegation- Resident burned another resident with a cigarette.
It is alleged Resident #1 had cigarette burns on the skin that were caused by another resident at the facility. On 11/30/23 LPA interviewed ED regarding the above allegation, ED denied the allegation above

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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-20231120195648

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 12/14/2023

NARRATIVE

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stating that no resident has disclosed being burned with a cigarette. Per ED, smoking is only allowed in the smoking patio which is located at the back of the facility building, ED continued to state that residents wear a pendant in case they need help and that staff conduct rounds to ensure safety. Per ED, staff will intervene, de-escalate, talk to residents involved, report to family, Primary Care Practitioner, and document if any such incident had occurred. 11/30/23, LPA interviewed S1—S8, 8 out of 8 staff interviewed denied the above allegation. 8 of 8 staff interviewed stated they did not have any knowledge of any resident being burned with a cigarette. On 11/30/23 LPA interviewed R2-R11 regarding the above allegations, 9 out of 11 residents interviewed denied the allegation. On 11/30/23 LPA interviewed W1 about the allegation above, W1 reported there were no burn marks observed during the body check conducted upon resident #1 admission to the new facility R1 is currently residing. On 11/30/23, LPA made an attempt to interview R1 via telephone due to R1 not currently residing at the facility. During the interview R1 was unable to answer LPA Villegas question due to communication barriers. As a part of the investigation LPA received photos of R1 with what appears to possibly be a burn mark. LPA was not able to verify when and where R1 sustained the burn marks as R1 is currently in a Skilled Nursing Facility.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted with Executive director (ED) Janie Acosta, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

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