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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 10/21/2020
Date Signed: 10/22/2020 08:40:49 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2020 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20200916115924
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:BRAD DEHAANFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 203DATE:
10/21/2020
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:BRAD DEHANNTIME COMPLETED:
10:21 AM
ALLEGATION(S):
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Facility residents have scabies
INVESTIGATION FINDINGS:
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On 10/21/2020 around 1pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019(COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via face time with Administrator Brad DeHann.

The Investigation consisted of the following: On 09/24/2020 LPA Calderon interviewed Director Sidonia Cordis and Administrator Brad DeHann and conducted a tour of the physical plant. LPA obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Dermatology medical records, Physicians Report and Medication list) and housekeepers training documentation and cleaning procedures. On 09/24/2020 LPA Calderon interviewed director (staff 1). On 09/29/2020 LPA Calderon interviewed LVN (Staff #2). On 10/01/2020 LPA Calderon interviewed Residents R1 – R10. On 10/12/2020 LPA interviewed housekeeper S3-S4.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
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 6
Control Number 11-AS-20200916115924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 10/21/2020
NARRATIVE
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The investigation revealed the following:

Allegation: Facility residents have scabies.
It is alleged on 9/16/2020 RP stated resident 1 got scabies while living in the facility. On 09/24/2020 LPA Calderon interviewed Director Sidonia Cordis and Administrator Brad DeHann, they stated they have no knowledge of any residents having scabies in their room. They stated resident 1 had scabies. On 10/01/2020 LPA Calderon tried to interview R1 who could not answer questions regarding complaint. On 10/01/2020 LPA Calderon interviewed Residents # R2 – R11, all residents state they never got scabies while living in the facility and did not know of any residents who had scabies. R2-R11 state they their rooms are cleaned every week. On 09/29/2020 LPA Calderon interviewed Med-Tech Supervisor (Staff #2) who states that she did go into R1 room and confirmed R1 had a rash all over her body and confirmed R1 room had been clean to include R1 clothes and bed linen’s. On 10/12/2020 LPA Calderon interviewed S3-S4 who both confirm a deep cleaning was done for R1 room to included clothes and linen’s and they could not confirm scabies. On 10/16/2020 LPA received documentation from Coast Dermatology which confirms R1 was diagnosed with scabies on 10/15/2020.

Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted with Administrator Brad DeHann, and a hard copy was provided via email for records
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2020 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20200916115924

FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:BRAD DEHAANFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: DATE:
10/21/2020
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:TIME COMPLETED:
10:21 AM
ALLEGATION(S):
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Facility staff failed to seek resident timely medical attention
Resident sustained unexplained fall resulting in hospitalization
Resident's room is not maintained in a clean and orderly fashion
INVESTIGATION FINDINGS:
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On 10/21/2020 around 1pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019(COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via face time with Administrator Brad DeHann.

The Investigation consisted of the following: On 09/24/2020 LPA Calderon interviewed Director Sidonia Cordis and Administrator Brad DeHann and conducted a tour of the physical plant. LPA obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Dermatology medical records, Physicians Report and Medication list) and housekeepers training documentation and cleaning procedures. On 09/24/2020 LPA Calderon interviewed director (staff 1). On 09/29/2020 LPA Calderon interviewed LVN (Staff #2). On 10/01/2020 LPA Calderon interviewed Residents R1 – R10. On 10/12/2020 LPA interviewed housekeeper S3-S4.

The investigation revealed the following:

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20200916115924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 10/21/2020
NARRATIVE
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Allegation: Facility staff failed to seek resident timely medical attention.
It is alleged on facility staff failed to seek R1 timely medical attention for a rash and a fall. On 07/24/2020 Responsible Party (RP) was informed by staff #2 that R1 had developed rash on her body. On 08/03/2020 RP spoke to staff #3 regarding action plan for R1 rash. On 08/04/2020 RP received call from staff #1 regarding leg pain for R1 who was transported to the hospital. Hospital evaluation on 08/04/2020 was a left hip fracture and surgery was performed. On 08/28/2020 R1 was seen by Dermatologist who diagnosed R1 with scabies. On 09/09/2020 R1 had another outbreak and was seen by dermatology group of Torrance and was diagnosed with scabies. On 09/28/2020 LPA Calderon interviewed Administrator Brad DeHann, provided documentation that outline the facility scabies protocols for cleaning a room and the LVN treatment for a rash. Administrator stated that R1 was given timely medical attention. He stated when R1 rash was noticed by facility staff the procedures to treat a rash were implemented. Administrator stated regarding R1 hip fracture he was not aware resident sustained a possible fall, but when R1 complained of leg pain she was taken to the hospital. On 09/29/2020 LPA Calderon interviewed Staff #2 who stated that R1 medication is closely controlled, and R1 room had been cleaned timely. Staff 2 confirms R1 medical needs were given as needed. On 10/01/2020 LPA Calderon interviewed Residents R2 – R11, all residents stated that their medication is well controlled by staff and all their medical needs are taken care of and they are no issues.
Allegation: Resident sustained unexplained fall resulting in hospitalization.
It is alleged R1 was transported to the hospital from a fall and required surgery for fracture left hip. LPA received medical records from facility indicating that on 08/04/2020 staff 2 informed RP of left leg pain to R1 who was transported to the hospital. On 08/04/2020 R1 was evaluated by the hospital and confirmed left hip fracture but does not state how this happened.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20200916115924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 10/21/2020
NARRATIVE
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On 09/28/2020 LPA Calderon interviewed Administrator Brad DeHann, who stated he does not know how R1 fractured her left hip he stated he is not sure where and when R1 sustained the hip fracture. On 09/29/2020 LPA Calderon interviewed Staff #2 who stated she does not know how R1 fractured her left hip.

Allegation: Resident's room is not maintained in a clean and orderly fashion.
It is alleged on 9/16/2020 it was alleged the facility does not clean residents’ rooms. On 09/28/2020 LPA Calderon interviewed Administrator Brad DeHann, he confirms RI room has been deep cleaned and provided scabies protocols for cleaning rooms. On 10/12/2020 LPA Calderon interviewed S3-S4 who both confirm a deep cleaning was done for R1 room to included clothes and linen’s, rugs, bathroom and all areas of R1 room. On 10/12/2020 LPA interviewed housekeeper S3-S4 who confirm residents’ room are cleaned daily and there is a scabies protocols which is used. LPA Calderon toured R1 room and it appeared clean.


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.

A telephonic exit interview was conducted with Administrator Brad DeHann, and a hard copy was provided via email for records





SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20200916115924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2020
Section Cited
CCR
87468(a)(2)
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Personal Rights
Each resident shall have personal rights...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by ;

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Administrator will follow protocols of Department of Public Health. Administrator will provide copy of actions taken by' facility based on Department of Public Health's instructions. Due date 10/26/2020.
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Based on records reviewed and interviews conducted the licensee failed to ensure Residents #1 was afforded a safe and comfortable accommodations.
R1 was infected with scabies while in placement at facility. This poses a health & Safety risk to residents in care.

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Administrator will ensure all housekeeping staff receive training in scabies cleaning procedures.
Administrator shall submit to LPA by POC
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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.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
LIC9099 (FAS) - (06/04)
Page: 6 of 6