197608029-7-17-2025-11-AS-JHAD-DKXVVN-20250827164636

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 07/17/2025
Date Signed: 07/17/2025 02:50:53 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
07/14/2025 and conducted by Evaluator Zina Brown

COMPLAINT CONTROL NUMBER: 11-AS-20250714095011

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: 250	DATE:	07/17/2025
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Suzette Johnson (Administrator)		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee did not ensure bathroom was in good repair.
Licensee did not ensure required notices were visibly posted in the facility.
Staff did not allow resident to leave their room.

INVESTIGATION FINDINGS:

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

On 07/17/2025 at 8:27p, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint findings. During today's visit, LPA met with Suzette Johnson and the explained the purpose of the visit.

The investigation consisted of the following: On 07/17/2025, LPA interviewed Administrator (A1), Staff #1 - Staff #10 (S1 - S10) and Resident #2-#9 (R2 – R9) ; Resident 1 (refused to be interviewed during the investigation). LPA requested copies of the staff roster (dated 07/17/2025), resident roster (recieved 07/17/2025), Face Sheet & Emergency (for R1 - received on 07/17/2025), LIC 602: Physician Report (for R1 - dated 05/29/2025), Admission Agreement (for R1 - dated 06/24/2025), LIC 603: Preplacement Appraisal Information (for R1 - dated 06/24/2025), Service Plan (for R1 - dated 06/24/2025) and Work Order for Room 285 (created 06/23/2025)

Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025

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-20250714095011

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: 07/17/2025

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

The investigation revealed the following:
Allegation 1: Licensee did not ensure bathroom was in good repair.
It was alleged bathroom, is not working for days and they have not ask someone to come fix it.
On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated she is not aware of any recent issues with R1's bathroom and residents can report to the front desk where a work order is placed and maintenance will complete the order. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 2 of out of 10 staff confirmed the allegation. 8 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 8 out of 10 residents denied the allegation. 1 out of 10 residents were unsure or unaware of the allegation. At approximately 1:03pm, LPA conducted a tour of room 285 where Resident 1 (R1) resides and observed the following: the sink, shower and toilet operable and in good repair. At approximately 1:30pm, LPA conducted a records review of the work order (created on 06/25/2025) and did not observe any documentation to support the allegation. Based on interviews conducted, records review. and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED

Allegation 2: Licensee did not ensure required notices were visibly posted in the facility.
It was alleged that the facility its just plain walls with no emergency information or telephone.
On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated the required posting are publicly visible in the common areas of the facility which is a standard protocol. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 3 out of 9 residents confirmed the allegation. 4 out of 9 residents were unsure or unaware of the allegation. 2 out of 9 residents denied the allegation. Between the hours of 8:35am -8:40am, LPA conducted a tour of the facility and observed in the main lobby area posted on the wall are following: the facility license, the Emergency Disaster Plan for Residential Facilities, the Long Term Ombudsman contact information, and the California Department of Social Services Community Care Licensing Division Centralized Complaint & Information Bureau contact information. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED.

Report continues on LIC 9099

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250714095011

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: 07/17/2025

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 3: Staff did not allow resident to leave their room.
It was alleged the facility won't let resident out of the room. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated residents are only restricted from common areas in the event that a resident is on isolation due to testing positive for COVID. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 10 out of 10 residents denied the allegation. Between the hours of 8:35am -8:40am, LPA conducted a tour of the facility and observe residents throughout the facility in common area. Upon records review, R1 is diagnosed with dementia as stated in R1's - LIC 602A Physician's Report for Residential Care Facilities for the Elderly (RCFE). On the LIC 602 under Section 14. Mental Condition it states (k). Able to Leave Facility Unassisted is check of NO. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED.

On 07/17/2025, LPA attempted to interview Resident #1 (R1) who declined to be interviewed about the three allegations.

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 allegations are UNSUBSTANTIATED.
Exit interview conducted with Suzette Johnson (Administrator) & copy of the report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3