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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 05/24/2024
Date Signed: 05/24/2024 11:28:48 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
07/29/2022 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20220729081919
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:REGGIE JONESFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 240DATE:
05/24/2024
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Janie Acosta/Executive DirectorTIME COMPLETED:
11:28 AM
ALLEGATION(S):
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Questionable death.
Resident fell while in care.
Resident was left on floor for an extended period of time.
Staff did not seek medical attention to resident.
Staff mishandled resident's medications.
Staff do not answer facility phone.
INVESTIGATION FINDINGS:
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On 5/24/24, Licensing Program Analyst LPA Alfonso Iniguez conducted a subsequent complaint visit to deliver findings for the complaint assigned to LPA Calderon on 7/29/22. LPA Iniguez met with Janie Acosta/Executive Director and explained the purpose of the visit.

During this investigation, LPA Calderon interviewed Resident (R1-R14), Administrator (A1), staff (S1-S5). These interviews were conducted on 05/05/2023 and 07/20/2023. On 07/20/2023 LPA Calderon obtained and reviewed the following: Needs and Service Plan (dated 06/08/2022), Pre-Placement Appraisal (dated 05/15/2022), Physicians Report (dated 03/29/2022), complaint form (dated 07/26/2022), Incident report (dated 07/16/2022 and 07/25/2022), Regal Specialty Pharmacy (dated 05/04/2022), Monterey wellness center (dated 05/11/2022) for R1. On 10/25/2022, Community Care Licensing Investigation Branch (IB) confirmed participation in this investigation and Investigator Ryan Philippe was assigned to this case. Investigator Philippe provided an IB report after concluding IB’s investigation which revealed the following:

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
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 7
Control Number 11-AS-20220729081919
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: 05/24/2024
NARRATIVE
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The investigation revealed the following:

Allegation 1: Questionable death.

This complaint alleged that (R1) death was questionable.

On 10/25/2022, LPA Calderon reviewed the department's Investigation Branch (IB) Investigator Ryan Philippe's report. The investigator's report stated that interviews were conducted with witnesses and staff members. On 07/26/2022 at approximately 10:00 hours, In-Home support services (IHSS) staff stated that R1 was alive in the morning. That following afternoon, at approximately 12:45 hours, IHSS staff entered (R1)'s room and discovered (R1) sitting on the toilet with their pants down, "sitting sideways," (IHHS) staff managed to get (R1) upright. (IHSS) staff screamed for help, and facility staff responded immediately. Staff members began life preventative measures (CPR) and called 911. When 911 arrived, they took over the life-preventative measures for (R1). In the (R1)’s personal folder were orders of "Do Not Resuscitate" (DNR) dated 03/01/2022 signed by (R1) and R1's conservator as a witness." 911 stopped, and (R1) was pronounced dead at the scene. Long Beach Police Department (PD) DR#: 220036549 Officer J. Clark's #11410 observed R1's body and found no "bruising, injury, or other signs of foul play." (R1) had died of natural causes, according to (R1)'s conservator.


Evaluation Report continues LIC 9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20220729081919
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: 05/24/2024
NARRATIVE
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Allegation 2: Resident fell while in care.

The complaint alleged that (R1) fell while in care.

On 10/25/2022, LPA Calderon reviewed the department's Investigation Branch (IB) Investigator Ryan Philippe's report. The investigator's report stated that (R1), a resident in the assisted living of Vista Del Mar Senior Living, had an unwitnessed fall in (R1)'s room. Night shift staff asked (R1) how they got on the floor, and (R1) replied: "I fell on my buttock trying to get my dessert on the vanity." Staff assessed (R1) and found no visible signs of injuries. The internal incident report noted, "Please keep monitoring." Since (R1) was a resident in assisted living and did not need assistance with ADLs or mobility.

LPA Calderon interview with Administrator: (A1). (A1) stated that residents fall due to age and health and that (R1) has fallen in the past. In addition, (A1) stated that facility staff helped (R1) and provided medical aid when they needed.

LPA Calderon interviewed staff (S1-S5), (5) out of (5) stated that (R1) lives in the assisted living section of the facility and does fall due to age and health issues.

LPA Calderon interviewed residents (R2-R14), (6) out of (13) stated that they have never fallen. Also, (4) out of (13) stated that they had fallen in the past, and facility staff were always quick to aid.

LPA Calderon could not interview (R1), they had passed away.

LPA Calderon reviewed the incident report (dated 07/25/2022), which stated that facility staff promptly found (R1) on the floor in their room. (R1), who had lost balance, was not injured, and got off the floor alone.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20220729081919
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: 05/24/2024
NARRATIVE
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Allegation 3: Resident was left on the floor for an extended period.

This complaint alleged that staff left (R1) on the floor for an extended period.

LPA Calderon interviewed Administrator: (A1). A1 stated that facility staff did not leave any resident on the ground for an extended period unless there was a medical need not to move the resident. Also, (A1) stated that (R1) did fall to the floor in their room and was found by staff within 10 minutes of the fall. In addition, (A1) stated that facility staff checked on all residents per shift, and no resident in care had been left on the floor for an extended period.

LPA Calderon interviewed facility staff (S1-S5), (5) out of (5) stated that (R1) was checked regularly and was found on the floor on 7/25/2022. In addition, (5) out of (5) facility staff stated that 5 to 10 minutes went by until a staff found (R1) on the floor. Also, (5) out of (5) facility staff stated that no resident has been left on the floor for more than 5 minutes.

LPA Calderon interviewed residents (R2-R6, R10, and R13), (13) out of (14) stated that they had fallen in the past, and on average, it takes 5 to 10 minutes for staff to help unless residents get off the floor on their own.

LPA Calderon could not interview (R1), they had passed away.


LPA Calderon reviewed the incident report (dated 07/25/2022). The report states that facility staff found (R1) on the floor in their room. (R1) lost balance and was not injured. (R1) got off the floor by themselves. In addition, LPA Calderon reviewed the preplacement appraisal (dated 05/15/2022); (R1) had health issues, was non-ambulatory, and needed assistance getting in and out of bed. Moreover, LPA Calderon reviewed (R1)’s needs and services plan (date 06/08/2022). (R1) had health issues and ambulated with a walker.

Evaluation Report continues LIC 9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20220729081919
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: 05/24/2024
NARRATIVE
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Allegation 4: Staff did not seek medical attention from residents.

This complaint alleged that staff did not seek medical attention for (R1).

LPA Calderon conducted an interview with Administrator (A1). (A1) stated that all facility staff had the authorization to call 911 if needed. Also, (A1) stated that facility staff are trained to call the RN or LVN for residents' medical needs and, if needed, to call 911.

LPA Calderon interviewed facility staff (S1-S5), (5) out of (5) stated that staff had called 911 in the past when a resident was not responding to urgent care provided. Also, (5) out of (5) facility staff stated that the facility offers additional training on calling 911, RN, or LVN. In addition, (5) out of (5) facility staff stated that (R1) was provided with the best care possible.

LPA Calderon interviewed residents (R2-R14), and (13) out of (14) stated that the facility staff provides medical care to any resident who needs it. Also, (13) out of (13) residents stated that facility staff has called 911 for residents and facility staff acts quickly on residents' medical needs.

LPA Calderon could not interview (R1), they had passed away.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20220729081919
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: 05/24/2024
NARRATIVE
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Allegation 5: Staff mishandled residents’ medications.

This complaint alleged that staff mishandled (R1) medications.

LPA Calderon interviewed with Administrator (A1). (A1) stated that no medication errors had happened, but if they happen, corrections are addressed with additional staff training if a mistake is made. In addition, (A1) stated that the facility has new electronic Medication Administration Records (MARs). With these latest (MARs), facility staff could avoid making more mistakes on (R1) or other resident's medications. In addition, (A1) stated that all facility staff handling medications are provided with the necessary training.
LPA Calderon interviewed facility staff (S1-S5), (5) out of (5) stated that no medication errors were made, and in case they happened, facility staff addressed them and corrected the issue. In addition, (5) out of (5) facility staff stated that if an error is made, the error is reported to the RN or LVN, and the resident’s family is also informed. Also, (5) out of (5) facility staff stated that training is provided to all who handle residents’ medications. Moreover, (5) out of (5) facility staff stated that no errors were found regarding (R1) medications. Furthermore, (5) out of (5) facility staff stated that the new (MARs) are being used, and it is hard for any error to happen.
LPA Calderon interviewed residents (R2-R14). (13) out of (14) stated that no medication errors have occurred with their medications. Also, (13) out of (13) residents stated that if a medication error is made, facility staff corrects the error.

LPA Calderon could not interview (R1), they had passed away.

LPA Calderon reviewed the Monterey Healthcare medication summary report (dated 05/11/2022) and observed (7) medications ordered by phone for (R1). Also, LPA Calderon reviewed the authorization from Regal Specialty Pharmacy (dated 05/04/2022) given to (R1)’s family to order their medications. LPA Calderon did not find discrepancies in (R1)’s medications.



Evaluation Report continues LIC 9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20220729081919
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: 05/24/2024
NARRATIVE
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Allegation 6: Staff do not answer facility phones.

This complaint alleged that staff do not answer the facility call button when (R1) pushes the button.

LPA Calderon interviewed with Administrator: (A1). (A1) stated that, on average, facility staff answers the call button within 10 to 15 minutes. In addition, (A1) stated that facility staff are trained to answer the call if they are near the resident’s room and push the call button. Also, (A1) stated that if a resident pushes the call button, the closest staff member will answer the call within 10 to 15 minutes. LPA Calderon interviewed facility staff (S1-S5), (5) out of (5) stated that when a resident pushes the call button, it takes, on average, 10 to 15 minutes for them to respond to the call.LPA Calderon interviewed residents (R2-R14), (13) out of (14) stated that when they push the call button, it takes 10 to 15 minutes for facility staff to answer the call. Also, (13) out of (13) residents stated that facility staff promptly answer the call button. In addition, (13) out of (13) residents stated that they have no problems with the services provided by facility staff.

LPA Calderon could not interview (R1), they had passed away.

During this investigation, LPA did not find sufficient evidence to support the above allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur.

An exit interview was conducted, and a copy of the Complaint Report was given to Janie Acosta /Executive Director..

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7