197608029-2-1-2024-11-AS-JHAD-D2NNDN-20240221092238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 02/01/2024
Date Signed: 02/01/2024 09:41:20 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
11/27/2023 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20231127174916

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: 242	DATE:	02/01/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Resident care director Sidona Cordis		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not prevent resident from physically assaulting another resident in care.

INVESTIGATION FINDINGS:

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On 02/01/24 at 9:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Resident care director Sidona Cordis as 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, and interviewed residents # 3-11 (R3-R11). LPA obtained copies of the following for R1 and R2, face sheet, emergency Identification form, service plan, physicians report, physicians orders and preplacement appraisal information. On 12/14/23 LPA interviewed resident #1 (R1), and staff #2-6 (S2-S6).

The investigation revealed the following:
Allegation- Staff did not prevent resident from physically assaulting another resident in care.

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: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

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-20231127174916

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: 02/01/2024

NARRATIVE

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It is being alleged that staff did not prevent resident from physically assaulting another resident in care. On 11/30/23 LPA interviewed (ED) regarding the above allegation, ED denied the above allegation stating that the facility is assessing residents, following up with psychiatrist and continued monitoring of resident’s behaviors to ensure this type of situation does not occur. ED also reported this was the first incident involving R1 and R2. On 11/30/23 LPA interviewed R3-R11 regarding the above allegation, 8 of 9 residents interviewed denied the above allegation reporting feeling safe at the facility. 1 of 9 residents interviewed reporting having a physical fight with roommate, however reports feeling safe at the facility as resident had a room change. On 12/14/23 LPA interviewed S2-S6 regarding the above allegation, 5 of 5 staff interviewed denied the above allegation. 5 of 5 staff reported residents are separated, residents are talked too, residents are assessed and are offered activities. On 12/14/23 LPA interviewed R1 regarding the above allegation, R1 denied the above allegation stating R1 could not remember the incident in question. LPA was unable to interview R2 as R2 is no longer a resident at this facility and there is no contact info on new location.

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 Resident care director Sidona Cordis 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: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

LIC9099 (FAS) - (06/04)

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