197608029-12-10-2024-11-AS-LVIS-DBTQR4-20241210112321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608029
Report Date: 12/10/2024
Date Signed: 12/10/2024 11:23:25 AM

Document Has Been Signed on 12/10/2024 11:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR/ DIRECTOR:	SUZETTE S. JOHNSON		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY: 300	TOTAL ENROLLED CHILDREN: 0	CENSUS: 242	DATE:	12/10/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:52 AM
MET WITH:	Executive Director Suzette Johnson		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE

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12/10/24 LPA Villegas conducted case management deficiencies visit in order to issue a citation observed during complaint investigation, control number 11-AS-20241209092305. LPA met with Executive Director Suzette Johnson as the purpose of the visit was explained. The facility failed to report an incident that occurred on 11/30/24 where resident #1 (R1) sustained a fall at the facility.

Based on observations LPA Villegas did observe documentation on nurse notes that R1 sustain a fall on 12/01/24. On 12/10/24 ED confirmed that incident occurred on 12/01/24 and confirmed an incident report was not submitted to CCLD within (7) days.

The licensee is being cited with Title 22 Reporting Requirements 87211(a)(1)(B)

Based on interviews, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8 by not reporting the incident to Community Care Licensing.

Exit interview conducted with Executive Director Suzette Johnson, appeal rights explained, and a copy of this report was provided.

Janae Hammond	TELEPHONE: (424) 544-1027
Lizeth Villegas	TELEPHONE: (818) 391-9974
	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/10/2024 11:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Reporting Requirements.Each licensee shall furnish to the licensing agency such reports as the Department may require...a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...(B) Any serious injury
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/13/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall read Title 22, Section 87211 “Reporting Requirements” and send a written statement to CCLD that they have read and understand this section and will report all resident's incidents in the future. Written statement must be submitted to LPA Villegas by 12/13/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Janae Hammond	TELEPHONE: (424) 544-1027
Lizeth Villegas	TELEPHONE: (818) 391-9974
	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

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