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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 06/13/2024
Date Signed: 06/13/2024 01:21:09 PM

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
06/06/2024 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20240606114646
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:JANIE ACOSTAFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 240DATE:
06/13/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:SIDONIA CORDISTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Staff did not provide resident an admission agreement.
Staff did not pick resident up after a medical appointment.
Staff prohibit resident form eating in their room.
INVESTIGATION FINDINGS:
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On 06/13/2024, Licensing Program Analyst (LPA) Antonine Richard conducted an initial 10-day visit regarding the complaint allegations above. LPA met with Resident Care Director Sidonis Cordis in the purpose of today’s visit was explained. later was joined by Executive Director Janie Acosta.


The investigation consisted of the following: On 06/13/2024, LPA interviewed the Resident Care Director, staff #1-5 (S1-S5), Resident #1-5 (R1-R5). LPA obtained copies of the following: staff and resident roster, as well as the following documents for R1, R2, R3, R4 and R5, face sheet, admission agreement, pre-placement appraisal, physicians report, needs and service plan.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
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 4
Control Number 11-AS-20240606114646
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: 06/13/2024
NARRATIVE
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Allegation 1- Staff did not provide resident an Admission Agreement.

It is being alleged that staff did not provide resident with an admission agreement since R1 moved to the facility on 05/31/24. On 06/13/24 LPA interviewed (ED) regarding the above allegation, ED denied the above allegation stating that the facility provides its clients with a copy of their admission agreement. If the client would like to have a copy of their admission agreement, they would only come to the office, and ask the staff, to make them a copy, from their client file. Sometimes client may ask for other items on their file, as they may need some for banking, social security, and medical. The staff in the office are available to assist the clients with whatever paperwork they need. LPA obtained a copy of the admission agreement for R1 upon reviewing the admission agreement, LPA discovered that the resident R1 signed the admission agreement on 05/31/24. LPA interview 5 residents (R1-R5) 4 out of 5 stated that the facility did let them sign the admission agreement and they told them if they need a copy they could come and get it in the office. LPA interviewed R1, client R1 stated that R1 don’t have any knowledge ever signing the form, but the admission agreement for resident R1 had the resident signature on it.

Based on the records review and interviews 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 violation did or did not occur, therefore the allegation is found to be unsubstantiated.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20240606114646
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: 06/13/2024
NARRATIVE
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Allegation 2 - Staff did not pick up resident up after a medical appointment.

It is being alleged that staff did not pick up resident after a medical appointment. Interviews were conducted with staff 1-2 (S1-S2), and residents 1-5 (R1-R5). LPA asked all residents, “Do you receive help with transportation when you need it?”, 4 out of 5 residents stated, “Yes”, Administrator does assist in transportation needs. LPA noted that Resident Care Director RCD stated that the facility offers to take residents to the appointments if requested and if they have issues with their schedule pick up. LPA interviewed five residents 4 out of 5 residents stated that they must schedule their medical appointment pick-up and drop-off in advance. The RCD noted that the insurance had already set up an arrangement for dialysis patients before they even move in. On 06/13/2024, during the review of the admission agreement in the section on transportation, stated that, “the facility would provide transportation to the nearest appropriate health facilities for medical and dental appointments, local destinations, banking, shopping, religious activities, and social services agencies.” There was no mention of transportation for dialysis patients. On 06/04/2024, ED stated that the facility staff helped some residents get to their medical appointment since their transportation's were running late, understanding that the residents, regular transportation BS and Access would bring them back to the facility if it were after 5:00 PM.


Based on records review, interviews 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 violation did or did not occur, therefore the allegation is found to be unsubstantiated.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 11-AS-20240606114646
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: 06/13/2024
NARRATIVE
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Allegation 3 - Staff prohibit resident from eating in their room.

It is alleged that staff prohibit resident from eating in their room resulting of resident missing several meals. During the interviews with five residents (R1-R5) 5 out of 5 stated that they never had any problem eating inside their room unless the rooms are being repair or the caregiver is mopping the floor. Resident also stated that the facility allows them to come down and get their food and go back to their room and eat it. LPA interviews five staff (S1-S5) 5 out of 5 all stated that some residents want to eat outside or in their room to watch TV, this is their choice they have rights we have to obey them. During the facility tour, LPA observed the residents eating breakfast inside their rooms. LPA asked Executive Director ED about staff prohibit residents from eating breakfast inside their rooms. ED stated that we cannot control what the resident brings inside their room let alone their breakfast, lunch, and dinner. She also stated we encourage the resident to come to the dining room to eat with other residents is to help them interact with one an another.

Based on the interviews and observation LPA could not to find 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 found to be unsubstantiated.

No deficiencies cited. exit interview conducted a copy of the report was provide to Executive Director Janie Acosta

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4