197608029-9-30-2020-11-AS-MVAO-BYKQ3V-20210225104920

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 09/30/2020
Date Signed: 09/30/2020 02:37:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/26/2020 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20200826114545

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	BRAD DEHAAN		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS: 203	DATE:	09/30/2020
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	ADMINISTRATOR BRAD DEHANN		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff removed insulin from resident's room without authorization.
Staff mismanages resident's medications.

INVESTIGATION FINDINGS:

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

On 09/24/2020 around 11am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019(COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via face time with Administrator Brad DeHann.

The Investigation consisted of the following: On 09/03/2020 LPA Calderon interviewed Administrator Brad DeHann and conducted a tour of the physical plant. LPA obtained copies of Resident #1s Pre-Placement Appraisal, MARS, Physicians Report and Medication list. On 8/27/2020 LPA Calderon interviewed Resident #1. On 9/11/2020 LPA Calderon interviewed Residents R2 – R10. On 09/14/2020 LPA Calderon interviewed Med-Tech Supervisor (Staff #1). On 09/30/2020 LPA interviewed S2-S3

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: 09/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020

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-20200826114545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 09/30/2020

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 removed insulin from resident’s room without authorization.
It is alleged on 8/26/2020 Staff #1 walked into Resident #1 room and stole R1 insulin medication with permission. On 09/03/2020 LPA Calderon interviewed Administrator Brad DeHann, he stated that the doctor for R1 took the insulin away on 06/08/2020 due to R1s memory faltering. R1 Doctor gave the insulin back to R1 on 08/27/2020 and the Administrator stated he is not in agreement with the Doctor giving the medication back to the resident to self-administer. On 9/3/2020 LPA Calderon interviewed R1 who stated that he had self-administered himself with insulin in the past and currently gives himself insulin. Resident #1 states that he left his room and when he came back his insulin was missing. On 09/11/2020 LPA Calderon interviewed Residents #2 R2 – R11, all residents state none of their medications had gone missing or stolen from their rooms. R2 – R11 state that they have not heard of any Residents medication being stolen or went missing. On 09/14/2020 LPA Calderon interviewed Med-Tech Supervisor (Staff #1) who states that he did go into R1 room and took the insulin without R1 being present. S1 stated the doctored ordered for the facility to remove the medication from the resident and administer it. Supervisor states that he never told, wrote, left any paperwork in Resident #1 room to advise that they took his insulin per the physicians’ instructions. On 09/30/2020 around 1pm LPA interviewed S2-S3 who all state that they review the MAR for the resident and inject the insulin tot the resident. All state that no medication has gone missing and they review the doctor’s orders prior to giving the medication to any resident. On 09/30/2020 LPA reviewed R1 file and observed 2 doctors orders indicting to take R1 insulin away and one order to give the insulin back.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20200826114545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 09/30/2020

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 mismanages resident’s medications.
It is alleged on 8/26/2020 Staff #1 stole Resident #1 insulin and then sold medication. On 09/03/2020 LPA Calderon interviewed Administrator Brad DeHann, he stated that R1 medication is controlled with the help of doctors, his staff and nurse. Administrator states that his staff keep track of all medication given to residents every day. On 09/14/2020 LPA Calderon interviewed Staff #1 who stated that R1 medication is closely controlled, and all medication is first reviewed by client’s doctors and based on the doctor’s instructed they give medication to their resident as prescribed. On 9/3/2020 LPA Calderon interviewed R #1 who stated that his medication is well controlled, and he has no issues. On 09/11/2020 LPA Calderon interviewed Residents R2 – R11, all residents stated that their medication is well controlled by staff and there are no issues. On 09/30/2020 LPA interviewed S2-S4 who confirm that they gave insulin to R1 per the doctors’ orders. On 09/30/2020 LPA reviewed R1s medications Administration Record and did not observe any discrepancies. R1s medications were being administered as prescribed according to the MAR.

Based on interviews conducted and documentation received throughout the course of the investigation there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

A telephonic exit interview was conducted with Administrator Brad DeHann and a hard copy was provided via email for records

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3