197608029-1-22-2021-11-AS-MVAO-BYYNPT-20210310093853

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 01/20/2021
Date Signed: 01/22/2021 01:39:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2020 and conducted by Evaluator Erik Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200717160219

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	BRAD DEHAAN		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS: 168	DATE:	01/20/2021
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Brad Dehaan, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident developed pressure injuries while in care
Facility has pests

INVESTIGATION FINDINGS:

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On this date, Licensing Program Analyst (LPA) Erik Brown conducted an unannounced complaint tele-visit to deliver findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Sidonia Cordis, the facility Assistant Administrator.

During the initial visit on 7/21/2020, LPA Brown conducted a 24-hour virtual visit with Staff #1 (S1) Brad Dehaan, the facility Administrator. LPA toured facility inside and out via FaceTime with Administrator. LPA also requested a copy of resident records to be sent to LPA via email or fax by Friday 7/24/2020.

The investigation revealed the following for allegation:

(Resident developed pressure injuries while in care)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

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-20200717160219

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 01/20/2021

NARRATIVE

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According to Investigation conducted by IB Investigator Peter Zertuche, “Hospice records show the victim had numerous pressure injuries with one unstageable injury and one at stage three which were documented during initial assessment. The victim continued to reside in the facility while the injuries worsened, according to hospice notes. Notes showed the facility contacted hospice numerous times to care for the wound as it had worsened. When asked why the victim was not taken to the doctor since hospice was not responding, the facility stated hospice was slow to respond and since the victim was on hospice, the hospice nurse cares for the injuries. The facility also stated that they are allowed to have residents with stage three pressure injuries since hospice treats them. The hospice waiver shows nothing regarding prohibited conditions. There was no police involvement in this case and the ombudsman office would not provide information citing confidentiality reasons. Based on the fact that the pressure injuries were present prior to hospice services and continued to worsen afterwards with no immediate medical care, at times, the case is closed with a substantiated finding.”
Based on review of medical documentation from R1’s Hospice Care company, wound care was initiated for R1 on 6/20/2020. Hospice records show that R1 had numerous pressure injuries with one unstageable injury and one at stage III which were documented during initial assessment. R1 continued to reside in the facility with stage 3 pressure injuries.

The investigation revealed the following for allegation:

(Facility has pests)

According to the interviews that were conducted by LPA Brown, residents and staff generally stated that the facility has had an issue with bugs. Staff and residents generally stated that the problem is being rectified by the extermination company that was hired to routinely service the facility.

Based on Investigator Peter Zertuche’s interviews, LPA Brown’s observations, the records that were reviewed (R1's hospice wound care plan, needs and services plan, physician's report, face sheet, pre-placement appraisal, service records from Orkin), and the interviews that were conducted by LPA Brown, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be substantiated.

A telephonic exit interview was conducted with Administrator Brad Dehaan and an electronic copy was provided via email for signature.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2020 and conducted by Evaluator Erik Brown

COMPLAINT CONTROL NUMBER: 11-AS-20200717160219

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	BRAD DEHAAN		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS: 168	DATE:	01/20/2021
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Brad Dehaan, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident not provided assistance with incontinence care
Insufficient staffing to meet resident's needs
Licensee is not providing basic services for resident
Licensee did not secure resident's personal care supplies
Facility faucets not delivering hot water
Hazardous item accessible to resident in care

INVESTIGATION FINDINGS:

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On this date, Licensing Program Analyst (LPA) Erik Brown conducted an unannounced complaint tele-visit to deliver findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Sidonia Cordis, the facility Assistant Administrator.

During the initial visit on 7/21/2020, LPA Brown conducted a 24-hour virtual visit with Staff #1 (S1) Brad Dehaan, the facility Administrator. LPA toured facility inside and out via FaceTime with Administrator. LPA also requested a copy of resident records to be sent to LPA via email or fax by Friday 7/24/2020.

The investigation revealed the following for allegations:

(Resident not provided assistance with incontinence care)
(Insufficient staffing to meet resident's needs)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

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-20200717160219

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 01/20/2021

NARRATIVE

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(Licensee is not providing basic services for resident)
(Licensee did not secure resident's personal care supplies)
(Facility faucets not delivering hot water)
(Hazardous item accessible to resident in care)

Based on interviews with staff, the facility staff repositioned R1 every 2 hours, and checked to see if R1 needed to be changed. Staff provided disposable briefs and made sure R1’s briefs remained dry. Staff provided R1 hip protectors and supplied R1 with a special mattress to help alleviate pain. According to interviews, staff would also continue to try and hydrate R1. A private caregiver was also hired for R1 in mid-June 2020 to ensure that R1 was receiving the proper care and attention that R1 needed. This private caregiver worked with R1 daily from 9am-7pm.

Staff, along with R1’s private caregiver, stated that the facility has sufficient staffing and provided basic services for R1 while performing hourly checks on R1. Staff ensured that R1 is changed, bathed, and fed. The facility has not had an issue with hot water, according to residents and staff.

R1’s personal care supplies were always secured in R1’s room. LPA observed supplies and staff stated that the facility has more than enough supplies in the facility.
According to interviews, it was found that R1 had an operational coffee pot in his room prior to his dementia diagnosis. In the past, R1 was able to function highly and do things independently at the facility. R1 was able to get coffee independently in the room. But as R1 went into decline, the coffee pot was removed from R1’s room.

Based on LPA Brown’s observations, the records that were reviewed (R1's hospice wound care plan, needs and services plan, physician's report, face sheet, pre-placement appraisal), and the interviews that were conducted by LPA Brown, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

A telephonic exit interview was conducted with Administrator Brad Dehaan and an electronic copy was provided via email for signature.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20200717160219

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/28/2021 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs... This requirement was not met	1 2 3 4 5 6 7	The Administrator will read Section 87465(a)(2) and send a written statement that Administrator has read the section and will abide. The written statement shall be sent to LPA Brown by the POC date.
	8 9 10 11 12 13 14	as evidenced by: Based on observation, record review and interview, facility staff did not meet the necessary medical needs for R1, which presented an immediate health and safety risk.R1's pressure injuries were present prior to hospice services and continued to worsen afterwards with no immediate medical care at times.	8 9 10 11 12 13 14
Type B 01/28/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on observation and interview, the facility has roaches as its primary pest, and also has had issues with bed bugs, and flying insects. This presents a personal rights risk to residents in care.	1 2 3 4 5 6 7	Administrator has corrected deficiency at the time of visit. Facility has a pest control company that comes out routinely and and as needed to treat the facility.
ILS	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: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

LIC9099 (FAS) - (06/04)

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