197608029-8-14-2025-11-AS-UCOL-DL7V7P-20250904161127

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 08/14/2025
Date Signed: 08/14/2025 04:01:01 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, 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
06/25/2025 and conducted by Evaluator Socorro Leandro

COMPLAINT CONTROL NUMBER: 11-AS-20250625150231

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:	08/14/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director, Suzette Johnson		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident fell due to staff neglect resulting in injury
Staff did not seek medical attention for resident

INVESTIGATION FINDINGS:

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On 08/14/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted a subsequent unannounced complaint investigation visit regarding the allegations listed above. LPA met with the Executive Director, Suzette Johnson, and the purpose of the visit was explained. LPA was granted entry to the facility

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

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 4

Control Number 11-AS-20250625150231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 08/14/2025

NARRATIVE

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Investigation consisted of the following:

On 07/02/2025, interviews were conducted, and records were gathered. Interviews conducted consisted of 10 resident interviews [Resident 2 (R2) to Resident 11 (R11) were interviewed]. Resident 1’s (R1) records were gathered which consisted of Medication Administration Record (MAR) from 03/2025 to 04/2025; Unusual Incident Report dated 05/16/2025; Progress Notes from 03/2025 to 04/2025; Admission Agreement dated 04/07/2025; Emergency Information dated 07/02/2025; Resident Assessment dated 02/25/2025; Preplacement Appraisal Information dated 02/28/2025; Appraisal/Needs & Services Plan dated 03/05/2025; Consent Forms dated 03/09/2025; Personal Rights dated 03/09/2025; and other pertinent information. Facility records were gathered which consisted of Resident Roster; Personnel Report dated 04/2025; Personnel Report dated 07/02/2025; LVN-Medication Technician Job Role Description; Time-Sheets from 04/05/2025 to 04/06/2025; Fall Risk Mitigation and Prevention Policy; Inservice Training from 03/05/2024 to 03/19/2025; Plan of Operation; and other pertinent information. On 8/14/2025, interviews were conducted, and records were reviewed. Interviews conducted consisted of 9 staff interviews [Staff 1 (S1) to Staff 9 (S9) were interviewed] and 2 witness interviews [Witness 1 (W1) to Witness 2 (W2) were interviewed].

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20250625150231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 08/14/2025

NARRATIVE

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Allegation: “Resident fell due to staff neglect resulting in injury”, it is being alleged that R1 fell due to staff neglect which resulted in R1 sustaining an injury. Interviews conducted with R2 to R11 revealed the following: 10 out of 10 residents denied the allegation. Interviews conducted with S1 to S9 revealed the following: 9 out of 9 staff denied the allegation. Interviews conducted with W1 to W2 revealed the following: 2 out of 2 witnesses denied the allegation. Records reviewed of R1’s facility notes revealed the following: on 04/05/2025 at 11:15 PM R1 had an unwitnessed fall; R1 was seen by Caregivers and by a Licensing Vocational Nurse; R1 was unhurt. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20250625150231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR SENIOR LIVING	FACILITY NUMBER: 197608029
	VISIT DATE: 08/14/2025

NARRATIVE

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Allegation: “Staff did not seek medical attention for resident”, it is being alleged that staff did not seek medical attention for R1. Interviews conducted with R2 to R11 revealed the following: 9 out of 10 residents denied the allegation. 1 out of 10 residents agreed with the allegation. Interviews conducted with S1 to S9 revealed the following: 9 out of 9 staff denied the allegation. Interviews conducted with W1 to W2 revealed the following: 2 out of 2 witnesses denied the allegation. Records reviewed of R1’s unusual incident report dated 04/06/2025 revealed the following: on 04/06/2025 at 3:00 PM, resident had a low oxygen level and 911 was called. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were provided.

An exit interview was conducted, and a copy of this report was left with the Executive Director, Suzette Johnson.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

LIC9099 (FAS) - (06/04)

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