197608029-3-19-2024-11-AS-RORN-D3YP2Z-20240403105646

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 03/19/2024
Date Signed: 03/19/2024 01:52:40 PM

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
03/13/2024 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20240313095158

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:	03/19/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director Janie Acosta		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff did not prevent a resident from assaulting another resident.

INVESTIGATION FINDINGS:

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On 03/19/24 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 03/19/24 LPA interviewed ED, staff #1-5 (S1-S5), Resident #1-10 (R1-R10), and witness 1 (W1). LPA obtained copies of the following; staff and resident roster, as well as the following documents for R1 and R2; facesheet, admission agreement, preplacement appraisal, physicians report, needs and service plan, physicians orders and staff notes.

The investigation revealed the following:
Allegation- Staff did not prevent resident from physically assaulting another resident in care.
It is being alleged that resident was assaulted by roommate while in care. On 03/19/24 LPA interviewed (ED) regarding the above allegation, ED denied the above allegation stating that the facility is assessing

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: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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-20240313095158

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: 03/19/2024

NARRATIVE

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residents, following up with psychiatrist, conduct room change, 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 as there has been no history of aggression for neither resident while in care. On 03/19/24 LPA interviewed R1-R10, 8 of the 10 residents interviewed denied the allegation above and reported feeling safe and believe staff would assist if they were being assaulted. On 03/19/24 LPA interviewed R1 regarding the above allegation, R1 reported being pushed by R2 after a verbal confrontation over a remote control. On 03/19/24 LPA interviewed R2 regrading the above allegation, R2 denied the allegation above and reported R2 did not physically touch R1. R2 continued to report that both R2 and R1 were pulling on a remote control and when R2 let the remote control go R1 lost R1s balance and stumbled but R1 did not fall or obtain injury. On 03/19/24 LPA interviewed S1-S5 regarding the above allegation, 4 of 5 staff interviewed denied the above allegation. 4 of 5 staff reported residents are separated, residents are talked to, and residents are assessed and are offered activities. 1 of 5 staff interviewed reported witnessing the incident and was able to intervene, per staff residents were pulling the remote control back and forth from each other when staff asked R2 to stop, let the remote go, and let staff handle the situation. As R2 let the remote go it is being reported that R1 lost R1s balance and took a step back but did not fall nor obtained injury. On 03/19/24 LPA spoke to W1 regarding the allegation above, per W1 W1 was made aware of the incident and after receiving the information of incident W1 does not have any safety concerns regarding R1. On 03/19/24 LPA conducted a review of R1 and R2s file and did not observe any prior incidents involving R1 and R2.

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: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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