197608029-10-23-2024-11-AS-UCOL-DADTZK-20241025151025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 05/22/2024
Date Signed: 10/23/2024 09:23:18 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
07/18/2022 and conducted by Evaluator Alfonso Iniguez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220718085319

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	REGGIE JONES		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS: 240	DATE:	05/22/2024
		UNANNOUNCED	TIME BEGAN:	09:57 AM
MET WITH:	Janie Acosta/Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care

INVESTIGATION FINDINGS:

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This is an amendment of the report dated 05/22/2024.
On 5/22/24, the Community Care Licensing Department (CCLD) conducted a subsequent unannounced complaint visit to deliver the complaint investigation findings. Upon arrival, CCLD staff was greeted by the administrator Janie Acosta, and the purpose of his visit was explained. CCLD staff and administrator conducted a health and safety check of facility.
The investigation consisted of the following. On 07/19/2022 CCLD initiated a complaint investigation and toured the facility including all common areas, kitchen, dining room. Copies of the following records were requested: Staff and Resident Roster, SIR reports for current complaint, physician report, needs and service plan, home health care plan Kindred Paramount Hospital medical records, College Medical Center of Long Beach medical records, doctors’ orders for R1. On 07/21/2022, the Department interviewed staff and residents. On 05/22/2022 the Department conducted a subsequent complaint investigation and delivered the initial complaint investigation findings. On 06/02/2024 the Department conducted a review of the complaint investigation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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 4

Control Number 11-AS-20220718085319

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: 05/22/2024

NARRATIVE

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The investigation revealed the following. Regarding the allegation “Resident sustained multiple pressure injuries while in care.” It is being alleged that resident R1 developed stage 3 and/or stage 4 Pressure Injuries while in care. The Department reviewed R1’s records, home health records and hospital records,and records indicate that R1 did not develop a stage 3 or 4 pressure injuries while in care and during R1’s hospitalization on 06/29/2022. Home Health Records indicate that R1 was being provided wound care for an unrelated injury between 04/22/2022 and 06/27/2022. Hospital Medical Records indicates that during R1’s hospitalization on 06/29/2022 the hospital wound care nurse assessed that R1 had a wound indicative of a stage 2 pressure injury, there was no documented evidence that R1 had a stage 3 or 4 pressure injury prior to R1’s admission at College Medical Center. Hospital Medical records also indicates that R1 was discharged from College Medical Center and admitted to Kindred Paramount Hospital on 07/14/2024. On 07/15/2024 Kindred Paramount Hospital staff diagnosed R1 with multiple unstageable injuries on R1’s back. Interviews revealed the following: R1’s unrelated wounds were healed and R1 was cleared by home health before R1 was sent to College Medical Center. 7 out of 7 staff indicate that R1 did not have a pressure injury prior to being admitted to the hospital. Staff denied the allegation and reiterated that they would have seen R1’s lower back area several times per day. Staff indicated that a home health nurse was treating wounds on the front of R1 upper thigh and R1 skin area. S3 performed diaper changes on R1, and this involved repositioning R1, cleaning and drying R1. S3 did not see any skin breakdown for R1.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20220718085319

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: 05/22/2024

NARRATIVE

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Based on interviews and record reviews, the preponderance of evidence standard has not been met. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation “Resident sustained multiple pressure injuries while in care”, is found to be UNSUBSTANTIATED.

No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20220718085319

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 05/23/2024 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615(a)(1)Persons who require health services for or have a health condition including, but not limited to...Stage 3 and 4 pressure injuries.This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will ensure to comply and review Title 22 Regulations, Section 87615 (a)(1) Prohibited Health Condition and create a plan of correction (POC) to ensure to stay in constant communication with medical professionals and if the resident’s medical condition elevates, meaning they require a higher level of care, Licensee/Administrator will ensure the resident is relocated to a skilled- nursing facility(SNF) or hospital and the relocation will take place immediately. Licensee/Administrator agreed to submit a verification of completion to CCLD/ El Segundo ASC office no later than 5/23/24.
	8 9 10 11 12 13 14	Based on records review and interviews conducted the facility retained resident 1 despite being informed by the home health agency that the resident had pressure injury. This poses a health & Safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Benita Yates	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

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