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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 07/15/2025
Date Signed: 07/15/2025 10:36:52 AM

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
12/09/2024 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20241209092305
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:SUZETTE S. JOHNSONFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 250DATE:
07/15/2025
UNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Executive Director Suzette JohnsonTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident sustained an unexplained fracture.
Staff did not seek medical attention to resident in a timely manner.
INVESTIGATION FINDINGS:
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On 07/15/25 The Department conducted a subsequent to deliver complaint findings, LPA Villegas met with Executive Director Suzette Johnson as the purpose of today's visit was explained.

The investigation consisted of the following: On 12/10/24 LPA Villegas obtained copies of resident #1 (R1) complete file, copies of the staff and resident rosters, copy of unusual incident report for 12/06/24, and copy of communication between staff regarding R1 from dates 12/01/24-12/09/24. On 01/22/25 The Department conducted interviews with staff #1-3 (S1-S3), and interviews with residents #2-4 (R2-R4). The Department was unable to conduct an interview with Resident #1 (R1) due to communication barrios. On 04/23/25 The Department obtained a copy of R1’s Kaiser Permanente Medical Records. On 05/05/25 The Department conducted a records review.

The investigation revealed the following:
Allegation: Resident sustained an unexplained fracture.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
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 2
Control Number 11-AS-20241209092305
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: 07/15/2025
NARRATIVE
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It is being alleged that a resident sustained an acute minimally displaced LI fracture while in care. On 01/22/25 The Department conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. Per 1 of 3 staff interviewed, on 12/01/24 resident reported sliding off bed, resident was assessed, resident denied any pain or injury, resident refused to go to the hospital, and resident was placed on “watch alert.” On 01/22/25 The Department conducted interviews with R2-R4 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. The Department was unable to conduct an interview with Resident #1 (R1) due to communication barrios. The Department conducted a review of medical records for R1, medical records revealed that R1 has a history of Osteopenia, subsequent L1 fracture, and mild degeneration (grade 2) to both the right and left hip, which has a higher risk of subsequent fractures. The Department conducted a review of R1’s file, per preplacement assessment dated 08/17/23 R1 is independent in bed mobility and transfer.

Allegation: Staff did not seek medical attention for resident in care in a timely manner.

It is being alleged that resident did not have a medical evaluation done after fall. On 01/22/25 The Department conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. Per 1 of 3 staff interviewed, on 12/01/24 resident reported sliding off bed, resident was assessed, resident denied any pain or injury, resident refused to go to the hospital, and resident was placed on “watch alert.” On 01/22/25 The Department conducted interviews with R2-R4 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. The Department was unable to conduct an interview with Resident #1 (R1) due to communication barrios. The Department conducted a review of R1’s file, per preplacement assessment dated 08/17/23 R1 is independent in bed mobility and transfer. Per review of communication log dated 12/01/24-12/19/24 R1 was being checked on by staff, per communication log there were no complaints of pain or discomfort, and resident refused to go to the hospital. The Department confirmed that an unusual incident report was sent to CCLD regarding R1’s fall on 12/01/24.

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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
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