197608029-6-14-2024-11-AS-JHAD-D7GW5B-20240724165852

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 06/13/2024
Date Signed: 06/14/2024 01:26:21 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
05/30/2024 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20240530110920

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:	09:30 AM
MET WITH:	Executive Director Janie Acosta		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Staff did not seek medical attention for resident.
Facilty staff failed to meet residents needs.

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 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, a list of all residents that require blood pressure checks (date: June 1st, 2024-June 5th, 2024), a list of residents that require blood glucose checks (updated 05/31/24). LPA obtained the following for resident #1 (R1) face-sheet (move in date: 03/14/24), physicians report (signed 03/12/24), pre-appraisal (signed 03/12/24), needs and service plan (signed on 03/20/24), admission agreement (signed 03/14/24), and MAR for months of April 2024-May 2024. LPA Villegas obtained the following resident #2 (R2) face-sheet (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, and physician’s orders for May 2024-June 2024. On 06/05/24 LPA Villegas also conducted interviews between 9:30am- 12:30pm, with ED,

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)

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Control Number 11-AS-20240530110920

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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and staff # 1-5 (S1-S5), LPA conducted a medication review for Residents #1-2 (R1-R2), LPA Villegas conducted interviews between 12:30pm-2:30pm with R#1-10 (R1-R10).
The investigation revealed the following:

Allegation: Staff did not seek medical attention for resident.

The details of the complaint allegation alleged that facility staff failed to obtain R1’s medication prescribed by Kaiser psychiatrist. On 06/05/24 LPA Villegas interviewed ED regarding the allegation above, ED denied the allegation above and stated that med room staff were unable to administer R1’s medication as R1 is obtaining medication from Kaiser pharmacy and Kaiser pharmacy had not delivered the medication when requested by R1. On 06/05/24 between 9:30am- 12:30pm, LPA Villegas interviewed S1-S5 regarding the above allegation, 5 of 5 staff denied the allegation above and stated that when an outside pharmacy is used medication refills are ordered 7 days prior to the medication running out. On 06/05/24 between 12:30pm-2:30pm LPA Villegas interviewed R1-R10 regarding the allegation above, 8 of 10 residents denied the allegation above and reported receiving medication daily and have not run out of meds. 2 of 10 residents did not wish to be interviewed. On 06/05/24 LPA Villegas conducted (2) medication reviews and did not observe any discrepancies.

Allegation: Facility staff failed to meet resident’s needs.

It is being alleged that the facilities med room staff failed to monitor R1’s blood pressure. On 06/05/24 LPA Villegas interviewed ED regarding the allegation above, ED denied the allegation above and stated that R1 does not have a doctor’s order for blood pressure checks. On 06/05/24 between 9:30am- 12:30pm, LPA Villegas interviewed S1-S5 regarding the above allegation, 5 of 5 staff denied the allegation above and stated that R1 does not have an order for blood pressure checks, however med room staff have been conducting blood pressure checks when it is requested by R1. On 06/05/24 between 12:30pm-2:30pm LPA Villegas interviewed R1-R10 regarding the allegation above, 5 of 10 residents interviewed denied the allegation above and reported med room staff conducted blood pressure checks daily, 3 of 10 residents interviewed reported not requiring blood pressure checks, 2 of 10 residents did not wish to be interviewed. On 06/05/24 LPA reviewed R1’s MAR for the months of April 2024 and May 2024 and did not observe a doctor’s orders for blood pressure checks. Based on 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)

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