197608029-1-31-2025-11-AS-JHAD-DEGUK8-20250305143843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 01/31/2025
Date Signed: 01/31/2025 01:19:48 PM

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
01/14/2025 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20250114124633

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: 239	DATE:	01/31/2025
		UNANNOUNCED	TIME BEGAN:	11:07 AM
MET WITH:	Executive Director Suzette Johnson		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff do not ensure medication is stored in originally received container.
Staff do not ensure the facility is free of insects.
Staff mismanaged residents' medication.
Staff are falsifying residents' medication administration record.

INVESTIGATION FINDINGS:

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On 01/31/25 Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Executive director (ED) Suzette Johnson as the purpose of the visit was explained.

The investigation consisted of the following: On 01/23/25 LPA requested copies of the following documents; staff and resident rosters, pest control reports for December 2024 and January 2025, and the following documents for residents #1-6 (R1-R6), emergency ID form, physicians reports, medication list, and Medication administration records (MAR) for January 2025. LPA requested copies of previous medication inservices held, ED to send copies via email by 01/24/25. On 01/23/25 between 10:20am- 11:43am LPA conducted interviews with R3-R10,LPA unable to interview R1-R2 as residents were out of the facility at the time of the visit. On 01/23/25 between 12 pm-12:25pm LPA conducted a medication review for R1-R6, and on 01/23/25 between 12:25pm- 1pm LPA conducted interview with Staff #1-2 (S1-S2). On 01/31/24 at 11:15am LPA conducted interviews with S3-S4, R1-R2, and ED.

Unsubstantiated

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: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

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 3

Control Number 11-AS-20250114124633

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: 01/31/2025

NARRATIVE

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On 01/31/25 LPA obtained copies of progress notes where it is Documented that physicians have been contacted regarding medication refusals.

The investigation revealed the following:
Allegation: Staff do not ensure medication is stored in originally received container.
It is being alleged that staff are preparing medications several days in advance.
On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff denied the allegation above. On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 9 of 10 residents interviewed denied the allegation above and reported meds are prepared in front of them by med room staff, 1 of 10 residents interviewed reported resident is provided with meds already in a med cup. On 01/23/25 LPA conducted a tour of the medication room and observed medications to be in their originally bottle or bubble packs.

Allegation: Staff do not ensure the facility is free of insects.
It is being alleged that there are roaches in the medication room.
On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 3 of 5 staff interviewed reported pet have been observed in the past, it was reported, and the med room was treated by pest control. 2 of 5 staff interviewed denied the allegation above. On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 6 of 10 residents interviewed denied the allegation above, 4 residents interviewed reported pest has been observed in the past however, it was reported to maintenance treatment has been provided. On 01/23/25 LPA conducted a tour of the medication room and did not observe any signs of pest, and med room was clean. On 01/31/25 LPA reviewed the pest control reports for December 2024 and January 2025, it is documented that the pest control company is coming out every week to treat rooms where pet have been reported as well as common areas.

Allegation: Staff mismanaged residents' medication.
It is being alleged that staff are being instructed to give a resident a medication that belongs to another resident because the resident was out of a particular medication.
On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. 4 of 5 staff interviewed reported there is an over flow of medications located in the med room to ensure a resident does not run out of medications.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250114124633

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: 01/31/2025

NARRATIVE

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On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 9 of 10 residents denied the allegation above and reported they have not run out of medications. 1 of 10 residents interviewed reported running out of medications from Kaiser due to a payment mis-communication with family. On 01/23/25 LPA observed there is an over flow of medications for residents stored in med room cabinet. Over flow was observed to be organized and labeled with residents name. LPA reviewed in-service held and attended by all medroom staff dated 09/25/24 and 10/16/24 for ordering and documenting medications.

Allegation: Staff are falsifying residents' medication administration record (MAR).
It is being alleged that med techs are entering meds as given even when they don't administer it.
On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. 4 of 5 staff interviewed reported MARs are documented in real time. On 01/23/25 LPA conducted a medication review for R1-R6, LPA did not observe any discrepancies on the MAR.

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.

Exit interview conducted, 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: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

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