197608029-3-1-2024-11-AS-JHAD-D32PWX-20240304104127

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 01/02/2024
Date Signed: 03/01/2024 11:22:12 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
12/26/2023 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20231226133527

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: 244	DATE:	01/02/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director Janie Acosta		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not prevent a resident from hitting another resident in care.
Staff did not prevent facility from becoming malodorous.
Staff did not keep facility free of insects.
Staff did not check resident's blood sugar.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 01/02/24 at 9:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegations above. LPA met with Executive Director (ED) Janie Acosta as the purpose of today’s visit was explained.

The investigation consisted of the following: On 01/02/24 LPA interviewed Executive Director (ED),Resident #1-10 (R1-R10), and staff #1-5 (S1-S5). On 01/02/24 LPA obtained copies of the following; Staff and resident rosters, housekeeping and janitotial schedule for December 2023 and January 2024, copy of invoice from Terminix dated 12/04/23, 12/18/23, a copy of terminix's last service visit dated 12/26/23, and a copy of vital signs log. On 01/02/24 LPA obtained copies of the following for R#1; face sheet, emergency I.D. form, physician’s report, medication list, needs and service plan, and admission agreement.

The investigation revealed the following:
Allegation- Staff did not prevent a resident from hitting 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: 01/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024

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 3

Control Number 11-AS-20231226133527

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: 01/02/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

It is alleged that staff did not prevent a resident from hitting another resident in care. On 01/02/24 LPA Villegas interviewed (ED) regarding the above allegation, ED denied the allegation above reporting that there were no recent reports made of a resident hitting another resident. Per ED, staff will de-escalate by separating residents, talking to residents and investigate what caused the incident. On 01/02/24 LPA Interviewed S1-S5 about the above allegation, 5 of 5 staff interviewed denied the allegation above stating they had no knowledge of a recent resident on resident incident. On 01/02/24 LPA Interviewed R1-R10 about the above allegation, 9 or 10 residents interviewed denied the allegation above and reported feeling safe at the facility. 1 of 10 residents interviewed admitted hitting a peer in the head, resident reported the incident occurred in their shared bedroom while no staff was present. Resident continued to report staff was later made aware of the incident and staff provided a room change, per resident this was the first time this has occurred.

Allegation- Staff did not prevent facility from becoming malodorous.

It is alleged that staff did not prevent facility from becoming malodorous. On 01/02/24 LPA Villegas interviewed (ED) regarding the above allegation, ED denied the allegation above reporting that common areas are cleaned 3 times a day. On 01/02/24 LPA Interviewed S1-S5 about the above allegation, 2 of 5 staff interviewed denied the allegation above, 3 of 5 staff interviewed stated the facility may become malodorous at times due to residents having accidents in common areas, however housekeeping is really good about cleaning right away. On 01/02/24 LPA Interviewed R1-R10 about the above allegation, 10 of 10 residents interviewed denied the allegation above.

Allegation-Staff did not keep facility free of insects.

It is alleged that staff did not keep facility free of insects. On 01/02/24 LPA Villegas interviewed (ED) regarding the above allegation, ED denied the allegation above. Per ED the facility has an ongoing pest control as a preventative measure for the facilities size. On 01/02/24 LPA Interviewed S1-S5 about the above allegation, 2 of 5 staff interviewed reported residents have reported insects. Per 2 of 5 staff interviewed, an inspection of the location will be done and it will be treated by terminix right away. 3 of 5 staff interviewed denied the above allegation, reporting no resident has reported any insects. On 01/02/24 LPA Interviewed R1-R10 about the above allegation, 4 of 10 reported seeing insects in the facility and reporting it, 6 of 10 residents interviewed denied the allegation above. On 01/02/24 LPA conducted tour of the facility and did not observe any insects.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20231226133527

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: 01/02/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff did not check resident's blood sugar.

It is alleged that Staff did not check resident's blood sugar. On 01/02/24 LPA Villegas interviewed (ED) regarding the above allegation, ED denied the allegation above. Per ED, blood sugars are checked according to the Doctors orders, and can be checked from 2 times a day to 4 times a day. On 01/02/24 LPA interviewed S1-S5 regarding the above allegation, 2 of 5 staff interviewed do not assist with medication administration, 3 of the 5 staff interviewed denied the above allegation. Per 3 of 5 staff interviewed, blood sugars are checked and documented daily according to Doctors orders. On 01/02/24 LPA interviewed R1-R10 regarding the above allegation, 9 of 10 residents interviewed were unable to provide information in regards to allegation above, 1 of 10 residents interviewed reported conducting own sugar checks as assistance from staff is not needed. On 01/02/24 LPA reviewed resident vital signs log and did not observe any discrepancies or missed blood sugar checks.

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 allegations are Unsubstantiated.

Exit interview conducted with Executive Director 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: 01/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3