197608029-4-8-2024-11-AS-UCOL-D49V8T-20240412161314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 05/03/2023
Date Signed: 04/08/2024 08:45:11 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, 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
12/07/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20211207093606

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	JAMES BENDER		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS: 231	DATE:	05/03/2023
		UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	ADMINSTRATOR JANIE ACOSTA		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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RESIDENT SUSTAINED MULTIPLE INJURIES WHILE IN CARE

INVESTIGATION FINDINGS:

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On 05/03/2023 around 09:00 AM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA Calderon met with Administrator Janie Acosta and the purpose of the visit was explained.

It is alleged that Facility staff are not properly trained. During this investigation, LPA Calderon interviewed R2-R12, A1, S1-S5. These interviews were conducted on 12/13/2021 and 03/30/2023. On 12/13/2021 LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, Medical Administration Records (MARS), Physicians Report, vehicle maintenance, driver 1 driving records.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

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-20211207093606

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 05/03/2023

NARRATIVE

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Allegation: Resident sustained multiple injuries while in care.
It is stated on 12/07/2021 resident sustained multiple injury while in care. On 12/07/2021 LPA could not interview R1 for complaint as R1 has an attorney. Letter from attorney states that R1 was inside facility van and was injured when driver came to a stop and R1 flew out of wheelchair on the van floor. On 12/14/2021 LPA reviewed IB report which did not find that R1 was injured when van came to a stop. On 12/14/2021 LPA reviewed medical records from IB report, records did not find that R1 was injured from falling out of the wheelchair. Medical report suggests minor injuries to resident knees. On 12/13/2021 LPA interviewed S5 driver who stated that resident 1 did fall out of wheelchair when S5 came to a stop at a red light. S5 states that R1had very minor injuries to R1 knees and refused to be taken to hospital or for 911 to be called. S5 states that R1 asked driver to drive R1back to the facility.

Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
12/07/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20211207093606

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	JAMES BENDER		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS: 231	DATE:	05/03/2023
		UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	ADMINSTRATOR JANIE ACOSTA		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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FACILITY STAFF ARE NOT PROPERLY TRAINED
FACILITY VEHICLE IS NOT IN GOOD REPAIR

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20211207093606

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 05/03/2023

NARRATIVE

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Allegation 2: Facility staff are not properly trained.
On 12/13/2021 LPA Calderon interviewed A1 for complaint. James Bender A1 states that his facility driver has been trained in how to properly transport residents in the facility van. A1 states that his driver was sick and the maintenance staff who is the backup driver was tasked to drive R1. A1 states that S5 was trained in how to transport residents in care. A1 states that S5 does not have a commercial license and drives residents from time to time when the normal driver is not working or is on the road or is sick. On 12/13/2021 LPA Calderon interviewed S5 for complaint. S5 states that S5 was giving training on how to properly transport resident in the facility van. S5 states that he just forgot to secure R1 and wheelchair down prior to leaving and when he braked R1 fell to the van floor. On 12/13/2021 LPA Calderon interviewed S3 for complaint. S3 states that S3 was sick on the date of incident and that S3 had trained S5 on how to properly transport a resident in the facility van. On 12/13/2021 LPA Calderon reviewed records and confirmed that S5 has a clean driving record and has been with the facility for over 10 years with no issues noted for his employment record. On 12/13/2021 LPA Calderon interviewed R2 who states that R2 has been driven in the van many times and staff has always secured him in then van while sitting in a wheelchair. On 03/30/2023 LPA Calderon interviewed R3-R12 for complaint. S6, S8 and S9 are in wheelchair and state that staff has always secured their chair and person prior to leaving and have never been injured while in transport. All other resident interviewed state that they have been transport to doctors’ meetings and have never had any issues or injuries.

Allegation 3: Facility vehicle is not in good repair
It is alleged that facility vehicle is not in good repair. On 12/13/2021 LPA Calderon interviewed A1 for complaint. A1 states that all facilities vehicles are given maintenance by third party vendors and the breaks are checked to make sure they are in good working order and all other vehicle services are done monthly to make sure the facility vehicles are in good working order. On 12/13/2021 LPA Calderon interviewed S3 and S5 for complaint. S3 and S5 state that the facility van has been services and had new breaks and tires prior to the accident. S3 and S5 state that the facility van was in working order and the incident did not happen due to vehicle failure. On 12/13/2021 LPA Calderon reviewed maintains records for facility van and noted that the facility van has been serviced and was in good repair prior to the incident.

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.

A exit interview was conducted with Administrator Janie Acosta, and a hard copy was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

LIC9099 (FAS) - (06/04)

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