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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 12/05/2024
Date Signed: 12/05/2024 05:01:39 PM

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
11/19/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241119135616
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:SUZETTE S. JOHNSONFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 246DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Suzette Johnson, Executive DirectorTIME COMPLETED:
05:14 PM
ALLEGATION(S):
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Facility staff did not respond to resident's calls for assistance
INVESTIGATION FINDINGS:
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On 12/05/24 The Department of Social Services, Community Care Licensing Division (CCLD) staff held a subsequent complaint visit at the above-mentioned facility. CCLD was met by staff one Suzette Johnson, exective director (S1).
The investigation consisted of the following: On 12/05/24 CCLD staff further interviewed four (4) residents (R11-R14) and two (2) staff (S4-S5). CCLD staff requested further records, including home health services visit notes for a resident. On 11/22/24 CCLD staff requested staff and resident roster, three (3) resident admissions agreement (R1, R6, R7) and toured the facility and interviewed ten (10) out of two-hundred and thirty-eight (238) residents (R1-R10) and five (5) out of one-hundred and five (105) staff. Resident seven (R7) was sleeping and denied CCLD staff's interview.
The investigation revealed the following:
Regarding the allegation "Facility staff did not respond to resident's calls for assistance", it has been alleged that staff do not respond to the call button.
Report continues, see LIC9099C.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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 3
Control Number 11-AS-20241119135616
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: 12/05/2024
NARRATIVE
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On 11/22/24, at 10:13AM, CCLD staff initiated an "emergency call" via pull cord, located in the restroom. CCLD staff interviewed a resident, within their room, and observed there was no response for at least 22 minutes. CCLD continued facility tour at 10:35AM, without CCLD observing any caretaker response. On 12/05/2024 CCLD staff tested five (5) additional pull cords located in residents' restrooms, four (4) of which were in working order. CCLD also tested the pull cord in the theatre room on the second (2nd) floor. CCLD did not observe a caretaker response. During the testing of the working pull cords, CCLD observed an average response time of 5 minutes. Interviews revealed that five (5) out of fourteen (14) residents and one (1) out of six (6) staff have agreed with the allegation. Based on CCLD staff's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited. Please see the attached LIC-9099D.

An exit interview was held with Suzette Johnson, Executive Director (S1), and a copy of the appeal rights, one (1) deficiency cited, and this report have been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20241119135616
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: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This has not been met as evidenced by:
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The licensee and CCLD staff have agreed that the facility will have their maintenance team inspect each room to ensure that resident's emergency pull cord are in working condition. All updates will be forwarded to CCLD staff at Mario.Leon@DSS.CA.GOV
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Based on CCLD's observations, the licensee has failed to ensure the facility has been maintained in good repair which poses a potential risk to residents in care.
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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: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3