197608029-9-11-2024-11-AS-JHAD-D9UMKW-20241008094126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 09/06/2024
Date Signed: 09/11/2024 10:34:04 AM

Substantiated

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
08/08/2024 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20240808083344

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:	DATE:	09/06/2024
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Executive Director Suzette Johnson		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff does not ensure resident is allowed to leave the facility at anytime with visitors.

INVESTIGATION FINDINGS:

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On 09/04/24 at 1:30 pm, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint to render findings. LPA met with Executive Director (ED) Suzette Johnson as the purpose of today’s visit was explained.

The investigation consisted of the following: On 08/16/24 LPA obtained copies of staff and resident rosters, visitors/visitation policy, resident sign in and sign out sheet or July 2024 and August 2024, and the following documents for R1: Emergency ID form, Admission agreement date 12/10/21, physicians report, physicians orders, needs and service plan, pre-appraisal, copy of POA document(s), and copy of documentation reporting POA's request regarding visitations. On 08/16/24 between 12pm- 1:15pm LPA conducted interviews with ED, staff #1-4 (S1-S4), and conducted a tour of the facility, there were no health and safety concerns observed. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with residents #1-10 R1-R10.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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 5

Control Number 11-AS-20240808083344

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: 09/06/2024

NARRATIVE

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The investigation revealed the following:
Allegation: Staff does not ensure resident is allowed to leave the facility at any time with visitors.
It is being alleged facility staff is not allowing R1 to leave the facility with visitors. On 08/16/24 between 12pm- 1:15pm LPA interviewed with ED regarding the allegation above, ED denied the allegation above and reported the facility is following POAs request regarding visitations outside the facility. ED continued to report that R1 has restrictions set in place by POA and that visitor(s) are aware of the restrictions. On 08/16/24 between 12pm- 1:15pm LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported that residents are allowed to go out of the facility with visitors unless there are restrictions in place per POA. On 08/16/24 LPA conducted interview with responsible party for R1, responsible party informed LPA that R1 has restrictions for visitations outside of the facility due to financial abuse concerns. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R1 regarding the allegation above, R1 reported it is not allowed for R1 to go out into the community with visitor although R1 would like too. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R2-R10 regarding the allegation above, 6 of 9 residents interviewed denied the allegation above and reported bring able to leave the facility with visitors, 2 of 9 residents interviewed reported not being able to leave the facility unaccompanied, 1 of 9 residents interviewed reported choosing to stay in the facility. On 09/04/24 LPA conducted review of the California all-purpose certificate of acknowledgment dated April 29, 2021 part 1 which is titled: Appointing an agent to make health care decisions, which reads “In this document I appoint an agent. That agent will make health care decisions for me in the future, if and when I no longer have the mental capacity to make my own health care decisions.” On 09/04/24 LPA reviewed provider information notice PIN 21-48-ASC page 3 title “Residents’ Right to Visitors, Telephone Calls, and Personal Mail” which details what POA agents are limited to the powers granted in the POA document. On 09/04/24 LPA conducted a review of title 22’s personal rights.
Based on records reviewed and interviews conducted facility staff violated R1 personal rights by allowing a POA that only has the authority to make health care on behalf of R1 to make decisions on R1 personal rights.

Based on LPAs observations and interviews which were conducted record review(s), 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.

exit interview conducted with Executive Director Suzette Johnson, appeal rights explained, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20240808083344

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 09/20/2024 Section Cited CCR 87468.1(a)(6)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night...	1 2 3 4 5 6 7	Administrator will submit a plan on how the facility will ensure R1 Personal Rights are not violated. Facility will reach out to the ombudsman and or law enforcement if and elder abuse is suspected.
	8 9 10 11 12 13 14	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The facility staff is following the instructions of a POA over healthcare regarding R1 right to leave the facility with visitors on outings. This poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
08/08/2024 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20240808083344

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:	DATE:	09/06/2024
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Executive Director Suzette Johnson		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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9

Staff did not ensure resident was allowed to have visitors.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20240808083344

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: 09/06/2024

NARRATIVE

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Allegation: Staff did not ensure resident was allowed to have visitors

It is being alleged that facility staff do not allow residents to have visitors. On 08/16/24 between 12pm- 1:15pm LPA interviewed with ED regarding the allegation above, ED denied the allegation above and reported that visitors are always welcomed during visitation hours. On 08/16/24 between 12pm- 1:15pm LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported visitors are allowed daily. On 08/16/24 LPA conducted interview with responsible party for R1, responsible party stated that there are no visitor restrictions for visits conducted inside the facility. On 08/22/24 LPA between 9:30am-11:45am conducted interviews with R1 regarding the allegation above, denied the allegation above and reported having visitors. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R2-R10 regarding the allegation above, 7 of 9 residents interviewed denied the allegation above, 2 of 9 residents interviewed reported not having any visitors that come by the facility.

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 Suzette Johnson, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5