197608029-5-22-2024-11-AS-JHAD-D65SE6-20240611134809

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 05/15/2024
Date Signed: 05/22/2024 11:45:03 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
05/08/2024 and conducted by Evaluator Sparkle Day

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240508145728

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: 245	DATE:	05/15/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Janie Acosta		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not ensure prescribed medical equipment was provided to resident in care.

INVESTIGATION FINDINGS:

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On 5/15/24 at 1:15 pm, Licensing Program Analyst (LPA) Sparkle Day conducted the initial Complaint visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1,(Resident care Director) who assisted with the visit.

Todays investigation consisted of the following: LPA Day obtained copies of the facility's roster for residents and staff. LPA reviewed (R#1)- (R#10) files, including Physicians Report , Admission Agreement , Appraisal/Needs and Service Plan, MARs and Face sheet . LPA interviewed the following: Staff #1-S#4 and witness #1(W-1.). LPA attempted to interview Resident #1 (R1) but R1 refused to be interviewed.

The investigation revealed the following:

Allegation: STAFF DID NOT ENSURE PRESCRIBED MEDICAL EQUIPMENT WAS PROVIDED TO RESIDENT IN CARE

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

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-20240508145728

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: 05/15/2024

NARRATIVE

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It is alleged that facility staff has orders to get resident #1 a medical bed, but has not done so. On 5/15/24 at around 1:45pm LPA interviewed (S1-(S3) regarding the allegation, 3 of 3 staff interviewed denied the allegation and stated resident #1 did not come to the facility with an order for a hospital bed. On 5/15/24 LPA interviewed witness #1 (W1), 1 of 1 witnesses interviewed denied the allegation that there was no hospital bed prescription for a resident #1. On 5/15/24, LPA conducted a file review of Resident #1 filed and did not observed any prescription for a hospital bed dated priori to R1 admission to the facility. On 5/15/24, LPA was unable to interview R1 since R1 refused to be interviewed.

Based upon this investigation, LPA finds that 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

An exit interview was conducted and a copy of this report was left with the Executive Director

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC9099 (FAS) - (06/04)

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