197608029-1-15-2025-11-AS-JHAD-DD968R-20250124193533

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 12/20/2024
Date Signed: 01/15/2025 09:47:01 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
12/12/2024 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20241212123022

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	SUZETTE S. JOHNSON		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS: 243	DATE:	12/20/2024
		UNANNOUNCED	TIME BEGAN:	08:36 AM
MET WITH:	Executive Director Suzette Johnson		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff allowed resident in care to leave the facility without supervision.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/20/24 at 8:36 am Licensing program analyst (LPA) Villegas conducted an unannounced initial complaint visit regarding the allegation above. LPA met with Executive Director (ED) Suzette Johnson as the purpose of the visit was explained.

The investigation consisted of the following: On 12/20/24 LPA obtain copies of the following: staff and resident rosters, resident sign in/sign out sheets for December 2024, and visitors log for the month of December 2024. On 12/20/24 LPA also obtain the following for R1: Admission agreement dated 09/13/24, emergency ID form, service plan dated 09/13/24, preplacement appraisal dated 09/13/24, and Physicians report dated 09/13/24. On 12/20/24 between 10am- 11am LPA conducted interviews with ED, staff #1-4 (S1-S4), responsible party. On 12/20/24 between 11am-12:30pm LPA conducted interviews with residents #2-3 (R2-R3), and between 12:30pm-12:45pm LPA conducted interview with R1.

The investigation revealed the following:

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

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 3

Control Number 11-AS-20241212123022

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: 12/20/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff allowed resident in care to leave the facility without supervision.
It is being alleged that R1 left the facility unassisted and was later found wandering the streets. On 12/20/24 between 10am- 11am LPA conducted an interview with Executive Director(ED) Suzette Johnson. Per ED Johnson, she was told that R1 informed staff that R1s partner would be coming by to pick R1 up, and R1 proceeded to make their way into the community. Per ED, the facility has procedures in place for when a resident is requesting to go out into the community. The reception desk will check August health to determine if a resident is able to go out without supervision, if a resident is not allowed, the resident is redirected.

On 12/20/24 between 10am- 11am LPA conducted interviews with staff 1-staff 4 (S1-S4) reading the allegation. Of those interviewed, 4 of 4 staff denied the allegation and reported there is always a staff member at the front desk to ensure that residents who cannot leave the facility unassisted do not make their way out into the community. Per S1, residents who cannot leave the facility unassisted have an asterisk next to their name in the computer. On 12/20/24, between 11am-12:30pm, LPA conducted interviews with residents #2-3 (R2-R3). Of those interviewed, 2 of 2 residents denied the allegation and reported being unable to leave the facility unassisted. On 12/20/24 between 12:30pm-12:24pm LPA conducted interview with R1 regarding the allegation. R1 stated during the interview they walked right out the front door of the facility, unassisted by staff.

On 12/20/24 LPA reviewed incident report sent to CCLD on 12/13/24. On 12/20/24 LPA conducted a records review for R1 and observed the physicians report, dated 09/13/24, which indicates resident has wandering behaviors and is unable to leave the facility unassisted. On 12/20/24 LPA reviewed Needs and Services plan, dated 09/13/24, which indicates that R1 had a wander guard device. On 12/20/24 LPA reviewed facility resident sign out sheet. Per the sheet, R1 was signed out by their responsible party on 12/11/24 at 10 am. On 12/20/24 LPA conducted interview with Witness 1 (W1), responsible party for R1. Per W1, they arrived to the facility around 1pm when it was determined R1 was out in the community and R1 was found at around 3pm.

Based on LPAs observations, interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8)are being cited on the attached LIC 9099D.

Exit interview conducted, appeal rights explained, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20241212123022

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: 12/20/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/03/2025 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations...	1 2 3 4 5 6 7	Licensee and Executive Director will submit to the department a plan detailing what measures the facility is taking to ensure this dificiency does not reoccur moving forward. Licensee and Executive Director will ensure all residents are reassessed when a change in condition is observed.
	8 9 10 11 12 13 14	this requirement was not met as R1 who has a dementia diagnosis was able to leave the facility unassisted which poses/posed a potential health, safety or personal rights risk to persons 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: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3