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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 09/12/2024
Date Signed: 11/26/2024 10:44:41 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
06/04/2024 and conducted by Evaluator Sparkle Day
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240604125752
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:JANIE ACOSTAFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 235DATE:
09/12/2024
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Sidonia Cordis,, suzette Johnson Resident Care DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Staff neglect resulted in the death of residents
Staff did not prevent a resident from causing self harm
INVESTIGATION FINDINGS:
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This report serves as an amendment to the 9/12/2024 report . The complaint findings reflected on the report dated 9/12/2024 remain the same and does not change. On todays date 11/26/24 LPA Day amended the 9/12/2024 report to soley include Administrators interview.
On 9/12/2024 ThLicensing Program Analyst (LPA) Sparkle Day conducted a susbsequent visit to the facility regarding the above allegations.
The investigation consisted of the following: LPA reviewed Death Reports of all Deaths in the facility from 3/2024 to 6/2024. R#1 passed away 3/15/2024 R#2 passed away 3/15/2024 R#3 passed away 3/15/2024 R#4 passed away 3/25/24 R#5 passed away 5/27/24 and R#6 passed away 5/29/24.
LPA interviewed Staff #1 - Staff #2. LPA contacted (3) hospice Agencies: W#1 - Allied Hospice, W#2 Devine Hospice, W#3 Apprea Hospice and W#4, Conservator of R#6

Regarding Allegation: Staff Neglect resulted in the death of residents
It was alledeged that staff neglect resulted in deaths of residents; During this visit LPA Day received the names of 6 residents who passed away from 3/2024 to 6/2024. Resident #1 (R#1) - Resident #5 (R#5) were all on Hospice during this time .
During this visit LPA contacted the hospice agencgies and confirmed that the deaths of R#1 - R#5 was due to end stage illnesses. LPA contacted conservator for R#6 and confirmed that the cause of death was
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 2
Control Number 11-AS-20240604125752
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: 09/12/2024
NARRATIVE
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due to an end stage illness. All Hospice agencies contacted and conservator where unaware of any staff neglect. Based upon this information gathered LPA finds that 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


Regarding Allegation : Staff did not prevent a resident from causing self harm

It was alleged that facility staff did not prevent a resident from causing self harm by cutting her wrist. During this visit LPA reviewed incident report of this incident dated 5/30/2024. LPA interviewed Staff #1 and Staff #2 which are both Med room staff who observed R#7 on day of incident. Incident report and staff interviews were consistent with incident: R#7 brought scissors to the Medroom and asked the staff to keep her scissors for her. Staff #1 asked R#7 why did she want them to hold the scissors for her and R#7 stated It would be safer for her. Staff took the scissors. Staff insist that R#7 did not seem distressed and acted normal. Later R#7 sustained a self cut to her wrist. LPA Day interviewed Administrator Suzette Johnson who explained the facility procedures of when a resident presumes to be distress or unusual behavior, that resident is put on a hourly watch. After R#7 brought the scissors to the Medroom S#1 alerted Administrator and was put on an alert. However R#7 cut herself within minutes of leaving the Medroom. LPA reviewed Physician report and Needs and Service Plan of R#7 which did not indicate any history of suicidal tendencies nor a history of cutting herself. During this visit LPA was unable to interview R#7 due to she has moved and whereabouts are unknown. Based on the information gathered and the interviews conducted LPA Day finds that the Staff had no knowledge of R#7 intent to harm herself , therefore could not prevent it. There is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED



An Exit interview was conducted with Suzette Johnson Administrator and Sidonia Cordis, Resident Care Director and a copy of this report was provided
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
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