197608029-4-11-2024-11-AS-UCOL-D49V8S-20240412161314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 04/04/2024
Date Signed: 04/11/2024 10:50:29 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
12/07/2021 and conducted by Evaluator Jose Calderon

PUBLIC

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: 232	DATE:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	02:13 PM
MET WITH:	Adminisrator Janie Acosta		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Resident sustained multiple injuries while in care.
Facility staff are not properly trained
Facility vehicle is not in good repair

INVESTIGATION FINDINGS:

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“This is an amendment of the Investigation Report (LIC9099) dated 04/04/2024, the purpose of this amendment is to provide additional information that this report supersedes the LIC9099 dated 05/03/2024.”

On 04/04/2024 Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to Vista Del Mar Senior Living to deliver the investigation findings for the allegations listed above. LPA Calderon met with Administrator Janie Acosta (A1) and the purpose of the visit was explained.

During this investigation, LPA Calderon interviewed Residents (R2-R12), Administrator (A1), staff (S1-S5). These interviews were conducted on 12/13/2021 and 03/30/2023. On 12/13/2021 LPA Calderon obtained copies of the following: Needs and Service Plan (dated 09/03/2021), Pre-Placement Appraisal (03/18/2018), Physicians Report (02/02/2018), hospital records (dated 03/22/2021), Incident report (dated 03/21/2021) for R1. LPA obtained vehicle maintenance record (dated 10/14/2021), driver D1 driving records (dated 03/02/2021).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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-20211207093606

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: 04/04/2024

NARRATIVE

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The investigation revealed the following:
Allegation 1: Resident sustained multiple injuries while in care.
On 12/7/2023, the allegation “Resident sustained multiple injuries while in care” was assigned to Investigator Peter Zertuche with the Department of Social Services Investigation Branch. Investigator Zertuche provided an investigation report to the El Segundo Regional office on 01/25/2022.
Investigator Zertuche’s report conclusion states, on 3/23/2021, R1 fell off R1’s wheelchair while being transported to R1 doctors' appointment. Interviews corroborated that R1 seatbelt was not properly secured during transport, which resulted in a fall when facility driver S5 “slammed” on the brakes at a yellow light. R1 attended the scheduled doctor appointment after the fall and a full examination was conducted. According to medical records, no serious injuries were found. A minor abrasion on the left knee was reported only. A follow-up doctor appointment for x-rays was scheduled for R1 on 3/25/2021, and no injuries were found on any part of R1’s body according to x-ray images reported in R1’s medical records. Investigator Zertuche conducted an interview with R1 who confirmed falling out of R1’s wheelchair during transit on 3/23/2021; however, R1 reported feeling “ok” and did not report that injuries were sustained as a result of the fall. Investigator Zertuche conducted an interview with S5, who confirmed not properly securing R1’s seatbelt and R1 fell out of R1’s wheelchair when S5 had to brake at a light on 3/23/2021. S5 observed R1 for injuries after R1’s fall and found R1 had a knee scrape and no other visible injuries. Based on interviews conducted, observations, and records reviewed, Investigator Zertuche was unable to find sufficient evidence to support “Resident sustained multiple injuries while in care”.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 04/04/2024

NARRATIVE

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Allegation 2: Facility staff are not properly trained

This complaint alleged that staff are not trained in how to transport residents in the facility van.

LPA Calderon conducted an interview with A1. A1 states that A1 facility drivers have been trained on how to properly transport residents in the facility van. A1 states that S3 is the facilities primary driver and when S3 is out, S5 is a back-up drive. LPA Calderon conducted an interview with S5, who states that S5 was provided training on how to properly transport residents in the facility van by management and the facility primary driver S3. S3 states S3 receives transportation safety training by an outside vendor. S3 then provides training to S5 the back-up driver. On 12/13/2021, LPA Calderon reviewed driving records and confirmed that S5 has a clean driving record and has been with the facility for over 10 years and no personnel issues on record. LPA Calderon conducted an interview with R2 -R13 for complaint. 12 out of 13 residents state that residents have been transported by facility staff in the company van and that all residents were secured with a seatbelt. Based on interviews conducted, observations, and records reviewed, LPA Calderon was unable to find sufficient evidence to support “Facility staff are not properly trained”.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 04/04/2024

NARRATIVE

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Allegation 3: Facility vehicle is not in good repair.

This complaint alleged that the facility vehicle is not maintained by mechanic. LPA Calderon conducted an interview with A1 who 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. LPA Calderon conducted an interview with S3 and S5. S3 and S5 state that the facility van has been serviced and had new brakes 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 Jiffy Lube (10/14/2021) records for facility van and noted that the facility van has been serviced and was in good repair prior to the incident.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the allegations: "Resident sustained multiple injuries while in care", "facility staff are not properly trained", and "faculty vehicle is not in good repair'' did or did not occur, are unsubstantiated.

An exit interview was conducted with Administrator Janie Acosta (A1), and a hard copy provided

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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