197608029-8-22-2024-11-AS-RORN-D8SLPN-20240904085611

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 08/22/2024
Date Signed: 08/22/2024 01:20:15 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
08/13/2024 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20240813145825

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:	DATE:	08/22/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Executive Director Suzette Johnson		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff do not ensure the facility is free from pests.
Staff do not ensure resident’s room is adequately cleaned.

INVESTIGATION FINDINGS:

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On 08/22/24 at 9:00 am, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Executive Director (ED) Suzette Johnson as the purpose of today’s visit was explained.

The investigation consisted of the following: On 08/16/24 LPA obtained copies of staff and resident rosters, house keeping schedule for August 2024, deep cleaning schedule and a copy of termix invoices for July 2024.On 08/16/24 LPA obtained copies of the following documents for R1: Emergency ID form, Admission agreement date 12/10/21, physicians report, physicians orders, needs and service plan, pre-appraisal, copy of POA document(s). On 08/16/24 LPA conducted interviews with ED, staff #1-4 (S1-S4), and conducted a tour of the facility, there were no health and safety concerns observed. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R1-R10, on 08/22/24 between 12pm-1:25pm LPA conducted interviews with S5-S6. On 08/22/24 LPA obtained copies of document(s) detailing what rooms have been treated for the month of June 2024-August 2024, terminix invoice for

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: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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 3

Control Number 11-AS-20240813145825

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: 08/22/2024

NARRATIVE

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June 2024-July 2024, Terminix inspection report, and documentation detailing the dates and times R1's bedroom is cleaned.

The investigation revealed the following:

Allegation: Staff are not ensuring that facility is free of pests.

It is being alleged that roaches have been observed underneath R1’s bed. On 08/16/24 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 once a week to spray the facility and bedrooms that require treatment. On 08/16/24 LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported that the facility is cleaned daily, bedrooms are cleaned daily and bedrooms are deep cleaned once a week. 4 of 4 staff interviewed also reported Terminix sprays the facility weekly. On 08/16/24 LPA interviewed W1 via phone who confirmed Vista Del Mar Senior Living have increased their services to once a week from twice a month. On 08/22/24 LPA conducted interviews with S5-S6, 2 of 2 staff interviewed denied the allegation above and reported bedrooms are being cleaned daily and that Terminix is coming out weekly to spray the facility and bedrooms that require treatment. On 08/22/24 LPA interviewed R1-R10 regarding the allegation above, 6 of 10 residents interviewed denied the allegation above, 4 of 10 residents interviewed reported observing and reporting pest in the past and reported that staff provided treatment. On 08/22/24 LPA toured R1's bedroom and did not observe any health or safety concerns nor pest.

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

It is being alleged staff are not cleaning R1’s bedroom floor properly. On 08/16/24 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 08/16/24 LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff denied the allegation above and stated that resident bedrooms are cleaned every day which consist of trash being removed, beds are made, and floors are cleaned. On 08/22/24 LPA conducted interviews with S5-S6, 2 of 2 staff interviewed denied the allegation above and reported that rooms are being cleaned daily and deep cleaned once a week. On 08/22/24 LPA interviewed R1-R10 regarding the allegation above, 9 of 10 residents reported bedrooms are cleaned daily, 1 of 10 residents reported bedroom is cleaned twice a day. On 08/22/24 LPA toured R1's bedroom and did not observe any health or safety concerns, documentation detailing when the bedroom was cleaned was observed on the

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20240813145825

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: 08/22/2024

NARRATIVE

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bedroom door. On 08/22/24 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 Suzette Johnson, 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: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC9099 (FAS) - (06/04)

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