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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 06/13/2024
Date Signed: 06/18/2024 11:32:21 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
05/29/2024 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20240529134240
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:
09:30 AM
MET WITH:Executive Director Janie AcostaTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff are not ensuring that facility is free of pests.
Facility staff failed to meet residents needs.
Staff are not safeguarding resident’s personal items.
Staff made inappropriate comments to resident.
Staff are not meeting resident’s laundry needs.
Staff are not ensuring resident's room is cleaned.
INVESTIGATION FINDINGS:
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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 (ED) 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, laundry and room cleaning schedule, invoice for Terminix services for the months of April 2024 and May 2024, and conducted a tour of facility. On 06/05/24 LPA Villegas obtained the following for residents #1 (R1): facesheet (move in date: 04/25/2024), physicians report (signed 04/16/24), pre-appraisal (dated 04/25/24), needs and service plan (dated 05/07/24), admission agreement (signed: 04/25/2024) and MAR for April 2024-June 2024. On 06/05/24 LPA Villegas obtained the following for residents #2 (R2): facesheet (move in date: 07/19/22), physicians report (signed 11/16/23), pre-appraisal (signed 07/16/22), needs and service plan (signed on 08/14/23), admission agreement (signed 07/14/22), MAR for month of May 2024, physician’s orders for May 2024-June 2024.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (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 4
Control Number 11-AS-20240529134240
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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On 06/05/24 LPA Villegas conducted interviews between 9:30am- 12:30pm, with ED, and staff # 1-5 (S1-S5), LPA conducted interviews between 12:30pm-2:30pm with R#1-10 (R1-R10).

The investigation revealed the following:
Allegation: Staff are not ensuring that facility is free of pests.

It is being alleged that R1 has been complaining about roaches. On 06/05/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that Vista Del Mar Senior Living has increased their contract with Terminix commercial who will now come out 3 times a month to spray the entire facility. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 4 of 5 staff interviewed denied the allegation above and reported that the facility is cleaned daily, and bedrooms are cleaned daily but are deep cleaned once a week. 1 of 5 staff interviewed reporting having no knowledge of the Terminix contract. On 06/05/24 LPA interviewed W1 via phone who confirmed facility is on the recommended treatment plan from Terminix pest control. W1 also reported Vista Del Mar Senior Living have increased their services to 3 times a month. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 5 of 10 residents interviewed reported that their rooms are cleaned daily and have not observed any pest in their bedrooms, 2 of 10 residents interviewed reported observing pest in their restroom and having the restroom sprayed right after, 2 or 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed.

Allegation: Facility staff failed to meet residents needs

It is being alleged that facility staff are storing personal belongings under R1’s bed, and R1 is unable to obtain belongings when needed. On 06/05/24 LPA toured R1’s bedroom and did not observe any belongings to be stored underneath the bed. On 06/05/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that personal belongings are stored in different areas of the bedroom, depending on the resident’s preference. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above and reported all residents have dresser, nightstand, and a shared closet where residents belonging can be stored and are accessible. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 7 of 10 residents interviewed denied the allegation above and reported their belongings are accessible as belongings are stored in their dresser(s), and closet. 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. On 06/05/24 LPA reviewed service plan and service plan does not specify

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (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 4
Control Number 11-AS-20240529134240
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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a need for items to be stored in a particular area of the bedroom.

Allegation: Staff are not safeguarding resident’s personal items

It is being alleged that S2 took R1’s wheelchair and gave R1 a wheelchair that was not R1’s. On 06/05/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that wheelchairs are not provided by Vista Del Mar Senior Living as wheelchairs are provided by resident’s insurance. ED also stated that all wheelchairs are labeled with the name of the resident it belongs too. On 06/05/24 LPA interviewed S2 regarding the allegation above, S2 denied the allegation above. S2 stated that upon R1’s arrival to the facility R1 was in a wheelchair that was too low which did not allow R1 to move around the facility comfortably, S1 states she provided R1 with a lender wheelchair that was higher while R1 was able to obtain a new wheelchair. S2 continued to report that after R1 received R1’s new wheelchair S2 asked for the lender wheelchair back; however, R1 was under the impression S2 was attempting to take away the new wheelchair from R1. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 5 of 10 residents interviewed denied the allegation above and reported that their wheelchair or walker have not been misplaced, 2 of 10 residents reported not using a wheelchair or walker, and 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. On 06/05/24 while conducting interviews LPA observed wheelchairs to be labeled with resident names.

Allegation: Staff made inappropriate comments to resident

It is being alleged that facility staff made inappropriate comments to R1. On 06/05/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that Ed has not been informed of any staff member speaking inappropriately to any resident in care. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 7 of 10 residents interviewed denied the allegation above and reported that staff treat them with respect, 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed.

Allegation: Staff are not meeting resident’s laundry needs

It is being alleged staff are not meeting R1’s laundry needs. On 06/05/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above and reported that R1’s personal laundry is washed once a week and linen is washed 1 once a week. On 06/05/24 LPA interviewed S1-S5 regarding the allegation

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (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: 3 of 4
Control Number 11-AS-20240529134240
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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above, 5 of 5 staff denied the allegation above and stated that not all residents are provided with laundry services, however, residents who have laundry services included in their admission agreement are provided with laundry services once a week. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 3 of 10 residents interviewed denied the allegation above and reported that staff provide laundry services weekly, 4 of 10 residents interviewed reported ding laundry themselves, 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. On 06/05/24 LPA reviewed R1’s admission agreement that states that R1’s laundry services are waived monthly as part of the assisted living waiver program. On 06/11/24 LPA reviewed laundry schedule for June 2024 that shows R1 will have laundry done on Saturday’s. On 6/11/24 LPA reviewed admission agreement page 3 letter B that states facility will launder towels and linens once a week, if a resident would like towels and linens to be laundered more frequently, facility will do so for an extra charge, as set forth in Appendix A.

Allegation: Staff are not ensuring resident's room is cleaned

It is being alleged staff are not cleaning R1’s bedroom. On 06/05/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above and reported that R1’s bedroom is cleaned daily and deep cleaned once a week per cleaning schedule. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above and stated that resident bedrooms are cleaned every day. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 7 of 10 residents interviewed denied the allegation above and reported that bedrooms are cleaned daily and deep cleaned once a week, 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. On 06/11/24 LPA reviewed admission agreement page 3 letter C which states facility will provide daily, light housekeeping services (bed making, trash removal, and general tidying) and deep clean weekly. If you, fail to do so, you understand that the facility may provide additional housekeeping services to your bedroom, and residents shall agree to pay for such services, as facility deem necessary. Facility will provide additional housekeeping services beyond the standard daily and weekly services for an additional fee, as described Appendix A.

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 HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (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: 4 of 4