197608029-7-19-2024-11-AS-JHAD-D7GW46-20240724165701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 07/19/2024
Date Signed: 07/19/2024 06:58:50 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
07/12/2024 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240712155653

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: 239	DATE:	07/19/2024
		UNANNOUNCED	TIME BEGAN:	08:21 AM
MET WITH:	Suzette Johnson		TIME COMPLETED:	09:59 AM

ALLEGATION(S):

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Staff did not prevent a resident from attacking another resident.

INVESTIGATION FINDINGS:

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On 07/19/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced visit at this facility. LPA was greeted by the Executive Director Suzette Jonhson. LPA explained the purpose of this visit was to deliver findings for the allegation mentioned above.

The investigation consisted of the following: A copy of the facility's roster for residents and staff, service records for resident #1 (R1's) Physician Report LIC 602A (dated: 06/07/24), College Medical Center Psychiatric Evaluation (dated: 04/21/24 and 05/24/24), Physical Examination/Progress Notes (dated: 05/25/24),Unusual Incident Report LIC 624 (dated: 07/15/24), Physician’s Orders Medications List (dated: 06/16/24), and (R2's) Preplacement Appraisal Information LIC 603A (dated: 04/24/24). Interviews with resident #1-#10 (R1-R11), Executive Director #1 (ED1) and staff #1-#4 (S1-S4). A tour of the faciltiy was conducted.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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-20240712155653

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: 07/19/2024

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff did not prevent a resident from attacking another resident.
The details of the complaint alleged resident #1 (R1) was attacked and the facility staff failed to prevent the physical assault. The complainant reported (R1) was physically assaulted by a another resident and sustained abrasions and lacerations on the front of the leg. The complainant did not provide further details on this matter.

Investigation revealed resident #1 (R1) came from Ocean Ridge Post Acute a skilled nursing facility. According to resident #1 (R1’s) Identification and Emergency Information LIC 601 (dated: 06/07/24) was admitted to Vista Del Mar on 06/07/24. (R1’s) Physicians Report LIC 603A (dated: 06/07/24) is non-ambulatory and requires assistance services with medication, transferring, bathing, dressing, and grooming.

On 07/18/24, between 09:30 am – 02:00 pm, the Department interviewed (5) out of (5) Executive Director #1(ED1) and staff #1-#4 (S1-S4) claimed this allegation was false. (A1 and S1-S2) claimed there was no physical assault that took place between resident #1 (R1) and resident #2 (R2). (S1-S2) reported that (R1) had an unwitnessed fall on 07/07/24 at 07:00 pm, (R1) sustained a minor skin tear on the leg and was assisted by a facility licensed vocational nurse/med-tech. (S1-S2) stated the skin tear was minor and did not require hospitalization. On 07/08/24 at 10:00 am, when being assisted by the care staff experienced combative behavior and delusional hallucinations and needed further medical evaluation according to the facility medical physician and was sent to College Medical Center on a (5150). (S3-S4) primary caregivers to (R1), explained that (R1) has displayed combative behavior when assisted with daily activity services. (S3-S4) stated (R1) had an intense fear of being touched and would respond by acting in inappropriate physical behavior with staff. (S2) reported when (R1) was admitted to Vista Del Mar from Ocean Ridge, (R1) already had multiple skin problems. (R1) is taking Eliquis, a blood thinner that can cause bruising and skin tears. According to (S2), both (R1) and (R2) require medical devices or mobility support as they are non-ambulatory. (R2) was diagnosed with Paralysis, which is a loss of muscle function in part of the body that would limit (R2's) ability to move, causing no physical assault on (R1). (S2) indicated that the facility's physician modified one of (R1's) prescribed medications to help improve (R1's) disorderly behavior on 06/21/24. (Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240712155653

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: 07/19/2024

NARRATIVE

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On 07/18/24, between 10:20 am 11:45 am, the Department interviewed (10) out of (10) residents (R2-R10) #2-#10 who denied having experienced physical assault while in care at this facility. (R2-R10) claimed not to have witnessed any physical altercations or assaults between residents. (R2-R10) praised the facility staff and mentioned they were responsive to their care and supervision. (R2) declared that (R2) had never engaged in physical contact with (R1).

On 07/18/24, between 12:30 pm – 12:55 pm, the Department interviewed (1) out of (1) witnesses #1 (R1’s) family representative who verified that (R1) has a history of physical aggression on facility aids. (W1) confirmed that due to agitation or anxiety (R1) has a history of disruptive behaviors in individuals who assisted (R1) with daily activities. (W1) reported the facility notified (W1) of the unwitnessed fall with the minor skin tear on the leg along with the disorderly conduct and was sent for further evaluation at College Medical Center.

On 05/16/24, between 10:00 am – 10:15 am, the Department interviewed resident #1 (R1). (R1) who is currently at College Medical Center and is being treated on (5250) was interviewed by telephone. (R1) was not able to carry a full conversation and was unable to provide statements.

As a result of the Department reviewing (R1’s) Physician Report LIC 602A (dated: 06/07/24), College Medical Center Psychiatric Evaluation (dated: 04/21/24 and 05/24/24), Physical Examination/Progress Notes (dated: 05/25/24), and Unusual Incident Report LIC 624 (dated: 07/15/24) verified (R1’s) has been evaluated with some form of mental disorder. A review of (R1’s) Physician’s Orders Medications List (dated: 06/16/24), revealed (R1) is on (22) routine medications. Thirteen (13) out of twenty-two (22) prescribed medications have side effects that can cause unusual skin irritation, peeling, or bruising per the National Institute of Health (ref: NIH). (R2’s) Preplacement Appraisal Information LIC 603A (dated: 04/24/24) confirmed (R2’s) health condition and ambulatory status verified the statement stated by (S2). Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above.

Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned in this complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview is conducted with Suzette Johnson, and a copy of the report is provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC9099 (FAS) - (06/04)

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