198602623-11-2-2021-28-AS-MVAO-CAZS9S-20220125124110

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602623
Report Date: 11/02/2021
Date Signed: 11/02/2021 03:39:53 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20211028095032

FACILITY NAME:	VISTA DEL MAR VILLAS		FACILITY NUMBER:	198602623
ADMINISTRATOR:	CHEN, DERICK		FACILITY TYPE:	740
ADDRESS:	3049 EAST DEL MAR BLVD		TELEPHONE:	(626) 215-1045
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	6	CENSUS: 5	DATE:	11/02/2021
		UNANNOUNCED	TIME BEGAN:	02:11 PM
MET WITH:	Christina Chen - Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are not following COVID 19 screening guidelines.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s)(LPA) Mary Flores and Jewel Baptiste conducted a complaint investigation visit regarding the above allegation. LPA met with Christina Chen administrator and explained the reason for the visit.

The investigation consisted of the following: LPAs interviewed Christina Chen administrator, observed facilities main entrance, and reviewed notebooks used for signing in and recording residents screening.

The investigation revealed the following: Regarding allegation; Staff are not following COVID 19 screening guidelines. It is alleged a visit was conducted on 10/07/2021 and visitor was not screened by RCFE. Visitor did not observe a thermometer or screening station/log in the RCFE. Upon arriving to the facility LPAs observed the following to the right of the centralized entrance a cabinet, a thermometer, pens, and a notebook were set up. Interview with administrator revealed facility is not screening family members as family members are vaccinated and staff are getting screened for temperature daily. Documentation reviewed revealed sign in notebook for October 2020 through November 2021 with date, name, and temperature some identify hospice nurses visitors, or other agencies visiting. (CONTINUED LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

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 28-AS-20211028095032

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR VILLAS	FACILITY NUMBER: 198602623
	VISIT DATE: 11/02/2021

NARRATIVE

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LPAs observed three (3) separate notebooks for residents in which residents vitals and temperature are recorded for March 2021 through October 2021. No records for staff screening were observed. LPAs did not observed the visitor in question name on the sign in notebook. Interview with staff #1 stated that there is screening in place and keep track in notebooks of temperatures.

Based on LPAs' observations, documents reviewed and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Christina Chen administrator and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211028095032

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR VILLAS	FACILITY NUMBER: 198602623
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/03/2021 Section Cited HSC 1569.50(a)(3)	1 2 3 4 5 6 7	HSC 1569.50(a)(3) The department...may suspend or revoke a license issued under this chapter upon any of the following grounds ...: Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will update their screening log and will maintain one for visitors, one for staff, and for residents, with all symptom question, and will ensure all visitors and staff sign in before entering the facility and will submit LIC 9098 to certify by 11/3/21 and a copy of the screening logs to LPA by 11/5/21.
	8 9 10 11 12 13 14	Based on interviews, observation, and documentation licensee is not following screening guidelines recommended. LPAs reviewed screening sign in notebooks and did not observed visitor in question sign in which poses an immediate Health, Safety, or Personal Rights violation 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: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC9099 (FAS) - (06/04)

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