197608029-11-6-2020-11-AS-JHAD-BZLU3G-20210330151331

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 11/05/2020
Date Signed: 11/06/2020 01:43:10 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
08/06/2020 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20200806142726

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: 203	DATE:	11/05/2020
		ANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	ADMINISTRATOR BRAD DEHAAN		TIME COMPLETED:	09:09 AM

ALLEGATION(S):

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Facility did not seek timely medical attention for resident after unwitnessed fall.

INVESTIGATION FINDINGS:

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On 11/05/2020 around 1pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019(COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via face time with Administrator Brad DeHaan.

The Investigation consisted of the following: On 08/06/2020 LPA Calderon conducted a tour of the physical plant. LPA obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Physicians Report and Medication list). On 08/06/2020 the RO referred the complaint to the Departments Investigations Branch and the investigation was assigned to Investigator Peter Zertuche. On 09/29/2020 IB interviewed Ombudsman. On 10/08/2020 IB interviewed Administrator Brad Dehaan (S1). On 10/21/2020 IB interviewed facility staffs S2, S3 and S4. On 10/21/2020 IB interviewed R1 Family Member (FM 1) and Family member (FM2).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200806142726

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: 11/05/2020

NARRATIVE

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The investigation revealed the following:

Regarding the allegation “Facility did not seek timely medical attention for resident R1 after unwitnessed fall.” On 08/04/2020 S2 received call from S3 regarding leg pain for R1 who was transported to the hospital. Hospital evaluation on 08/04/2020 was a left hip fracture and surgery was performed. IB attempted to interview R1 but was unsuccessful due to the residents confusion as a result of R1 dementia diagnosis. Facility staff interviewed stated R1 was physically capable of walking unassisted. IB conducted interviews with R1 family members (FM1-FM2) who confirmed R1 was independent with ambulating unassisted by staff. Review of R1 records did not indicate resident had prior history of falls while in care at the facility. All the parties IB interviewed on 09/29/2020, 10/21/2020, 10/22/2020 did not witness R1 fall and were unable to provide details of the incident. Based on information received it is documented R1 was transported to the hospital the same day the facility staff became aware the resident was in pain.

Based on interviews conducted and records reviewed the complaint is Unsubstantiated, it means that although the allegation may have happened or is valid; there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.

A telephonic exit interview was conducted with Brad DeHaan, Administrator and emailed a copy of this report for signature. Appeal rights discussed and provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020

LIC9099 (FAS) - (06/04)

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