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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 05/16/2025
Date Signed: 05/16/2025 11:57:31 AM

Substantiated


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
11/19/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241119135616
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:SUZETTE S. JOHNSONFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 251DATE:
05/16/2025
UNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Suzette Johnson, Executive DirectorTIME COMPLETED:
12:21 PM
ALLEGATION(S):
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Facility staff did not dispense medications as prescribed.
INVESTIGATION FINDINGS:
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On 05/16/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit at the facility to deliver findings. LPA was met by staff one, Suzette Johnson Exective Director (S1), and the purpose of the visit was explained.
The investigation consisted of the following: On 11/22/24 LPA requested staff and resident roster, three (3) resident admissions agreement (R1, R6, R7) and toured the facility and interviewed ten (10) out of two-hundred and thirty-eight (238) residents (R1-R10) and five (5) out of one-hundred and five (105) staff (S1-S5). Resident seven (R7) was sleeping and denied LPA's interview. On 12/05/24 CCLD staff interviewed four (4) residents (R11-R14) and two (2) staff (S5 & S6). LPA requested further records, including home health service visit notes for a resident.
The investigation revealed the following: Regarding the allegation, "Facility staff did not dispense medications as prescribed.". It has been alleged that a resident did not receive their weekly dosage of a medication, as ordered by resident's physician (Dr.), due to medication being misplaced by staff.
Report continues, see LIC9099-C.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
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 5
Control Number 11-AS-20241119135616
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: 05/16/2025
NARRATIVE
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Record reviews of the medication administration record (MAR) reveal that a doctor's order had been placed for the medication in question (M1) on September 5th, 2024 (09/05/2024). Though M1 is to be provided once per week (1x/week), M1 had been marked as having been administered to a resident nineteen (19) times during the month of September (09/2024). The MAR, following M1, indicates that a resident's Dr.'s order had been followed between the dates of 10/25/2024 through 11/07/2024. M1 was provided to the resident on November the eighth, 2024 (11/08/2024) and November the fifteenth, 2024 (11/15/2024), again following a resident's Dr. order, yet no more administration marks had been placed on the MAR during the month of November (11/2024). Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099-D.

One deficiency has been cited during today's visit, please see LIC9099-D.

An exit interview was held with Suzette Johnson, Executive Director, and a copy of appeal rights, this deficiency and this report have been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/19/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241119135616

FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:SUZETTE S. JOHNSONFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 251DATE:
05/16/2025
UNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Suzette Johnson, Executive DirectorTIME COMPLETED:
12:21 PM
ALLEGATION(S):
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9
Resident developed a pressure injury due to staff neglect
INVESTIGATION FINDINGS:
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On 05/16/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit at the facility to deliver findings. LPA was met by staff one, Suzette Johnson Exective Director (S1) and the purpose of the visit was explained.
The investigation consisted of the following: On 11/22/24 CCLD staff requested staff and resident roster, three (3) resident admissions agreement (R1, R6, R7) and toured the facility and interviewed ten (10) out of two-hundred and thirty-eight (238) residents (R1-R10) and five (5) out of one-hundred and five (105) staff. Resident seven (R7) was sleeping and denied CCLD staff's interview. On 12/05/24 CCLD staff interviewed four (4) residents (R11-R14) and two (2) staff (S5 & S6). CCLD staff requested further records, including home health services visit notes for a resident.

Report continues, see LIC9099-C.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20241119135616
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: 05/16/2025
NARRATIVE
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The investigation revealed the following:

Regarding the allegation, "Resident developed a pressure injury due to staff neglect". It has been alleged that a resident has not been rotated as often as needed. Although the facility does not keep a rotation log for the residents requiring this service, LPA interviews revealed that nine (9) out of fourteen (14) residents and all six (6) staff interviewed, out of one-hundred and five (105) staff, have not agreed with the allegation. Record reviews revealed that a resident did have a stage two (2) pressure injury, but on November nineteenth, 2024 (11/19/24) the same resident requested discharge from their home-health services provided by Excel Home Health in order to choose an alternate service(s) which are also related to a resident's health condition. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the alleged violation did occur. Therefore, the above allegation is found to be Unsubstantiated.

There have been zero (0) deficiencies cited during today's visit.

An exit interview was held with Suzette Johnson, Executive Director, and a copy of appeal rights and this report have been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20241119135616
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: 05/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2025
Section Cited
CCR
87465(a)(6)
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87465 Incidental Medical...care
(a) A plan for incidental medical...care shall be developed by each facility. The plan...provide for assistance in obtaining such care...: (6) When requested by...a record of dosages of medications shall be maintained by the facility.
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LPA and licensee have agreed that med-tech staff will undergo training to reiterate how important medication (med) management, including focus on med storage, is for residents in care. Licensee has agreed that facility will send inservice conference information, including the time included &
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This requirement has not been met as evidenced by: R1's medication admission record (MAR) in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
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 sign-in sheet, on or prior to the POC due date 05/23/2025, via email to LPA at mario.leon@dss.ca.gov
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5