197608029-6-14-2024-11-AS-JHAD-D7AS3M-20240718133122

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 06/13/2024
Date Signed: 06/14/2024 08:32:30 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
05/30/2024 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20240530104557

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: 240	DATE:	06/13/2024
		UNANNOUNCED	TIME BEGAN:	09:44 AM
MET WITH:	Executive Director Janie Acosta		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did ensure universal precautions were taken.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 06/13/24 Licensing program analyst (LPA) Villegas conducted a subsequential complaint visit to render findings regarding the allegation(s) above. LPA met with Executive Director Janie Acosta, as the purpose of the visit was explained.
The investigation consisted of the following: On 06/05/24 LPA Villegas obtained a copy of the following documents: staff and resident rosters, kitchen menu for April 2024-June 2024, in-services for March 2024, April 2024 and May 2024, and serve safe food handling certifications for all kitchen staff. LPA Villegas conducted a tour of facility kitchen and dining room to observe cleaning procedures. LPA Villegas obtained the following for residents #1-3 (R1-R3); facesheet, physicians report, pre-appraisal, needs and service plan, admission agreement and MAR for the last two months. LPA also conducted interviews between 9:30am- 12:30pm, with ED, and staff # 1-6 (S1-S6), LPA Villegas conducted interviews between 12:30pm-2:30pm with R#2-10 (R2-R10). On 06/13/24 at 10:10 am LPA Villegas interviewed Resident #1 (R1).
The investigation revealed the following:
Allegation: Staff did ensure universal precautions were taken

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
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 2

Control Number 11-AS-20240530104557

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

It is being alleged that R1 became ill due to the food served at Vista Del Mar Senior Living. On 06/05/24 LPA Villegas interviewed ED regarding the allegation above, ED denied the allegation above and stated all kitchen staff is trained on and are implementing all universal precautions. ED continued to report that the food service director provides initial training as well as enrolls new staff in reliase training for ServSafe certification. On 06/05/24 LPA Villegas obtained copies and verified that all kitchen staff have active ServSafe and food handler certification. On 06/05/24 between 9:30am- 12:30pm, LPA Villegas interviewed S1-S6 regarding the above allegation, 4 of 6 staff denied the allegation above and reported that all meals are fresh, there are no leftovers, temperatures are conducted daily, and that food quality checks are conducted daily. 2 of 6 staff reported not having any knowledge of the kitchen protocols. On 06/05/24 LPA Villegas toured facility kitchen with S1, LPA observed kitchen staff wash off dishes and utensils prior to placing them into the dish washer that provides sanitation. LPA Villegas observed all food stored in pantry to be dated and observed the refrigerator and freezer to have appropriate temperatures. LPA Villegas toured dinning room following lunch service and observed staff sanitizing all tables and chairs. On 06/05/24 between 12:30pm-2:30pm LPA Villegas interviewed R1-R10 regarding the allegation above, 2 of 10 residents interviewed refused to be interviewed, 7 of 10 residents interviewed denied the allegation above. The 7 of 10 residents interviewed stated they have not been sick due to the food provided at Vista Del Mar Senior Living. On 06/13/24 at 10:10 am LPA Villegas interviewed R1 regrading the allegation above, per R1 R1 went to the E.R. twice in May 2024 and was provided with Anti- Nausea, anti-diarrhea, and cepacol medication, and reports R1 has requested a no Mayonnaise diet moving forward. Based on observation, interviews, and records reviewed there is not enough evidence to support the allegation above.

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 Janie Acosta, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
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 2