197608029-9-5-2025-11-AS-SCIS-DM4TPW-20251003145458

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 08/05/2025
Date Signed: 09/05/2025 01:23:21 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
04/21/2025 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20250421123647

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:	08/05/2025
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Suzette Johnson		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not ensure residents dietary care plan is being followed
Staff do not ensure resident is provided with breakfast, lunch and dinner each day
Staff does not ensure adequate care and supervision is provided to residents

INVESTIGATION FINDINGS:

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

On 08/05/2025 at 3:00 p.m., The Department conducted an initial visit to gather information regarding the above allegations. The Department met with Executive Director Suzette Johnson and explained the purpose of today's visit. LPA was granted entry to the facility.

Investigation consisted of the following: On 04/28/2025, the department requested, reviewed and obtained copies of Resident Roster (Dated 04/28/2025), Personnel Report (Dated 04/28/2025), Dietitian's Report (Dated 03/28/2025) Weekly Menu (Dated 02/16/2025 - 05/03/2025) Resident 1's Records (Dated 04/28/2025) Resident 1's Progress Note (Dated 06/01/2024 - 04/28/2025), and Tray Service Request. Interviews were conducted, with staff 1-5 (S1-S5) and residents 1-10 (R1-10). We toured the facility kitchen. At 11:30 a.m., the Department observed residents eating well-balanced and nutritious meals. We observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.
See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

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-20250421123647

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: 08/05/2025

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

Continued LIC9099-C page 2

Investigation revealed the following:

Allegation: Staff do not ensure residents' dietary care plan is being followed.
On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. Five out of five (5 out of 5) staff members and nine out of ten (9 out of 10) residents stated that staff ensure residents' dietary care plans are being followed. They confirmed that staff consistently adhere to physician-prescribed dietary menus and that residents are served well-balanced, nutritious meals according to the doctors' orders. 5 out of 5 staff members and 9 out of 10 residents also stated that the facility does have a dietitian. R1 reported that staff do not ensure the residents' dietary care plans are being followed. LPA requested R1's physicians' report and reviewed the resident's special diet documentation. 5 out of 5 staff members confirmed that R1 is on a diabetic diet, and R1's physician's report, dated 05/28/2024, also indicated that R1 is on a diabetic diet. LPA observed the facility's regular menu as well as the diabetic alternative menu available for residents on a special diet. Staff stated that according to the residents' physicians' orders, they will accommodate special diets, including low sugar, carbohydrate, mechanical soft, and pureed options.

S1-S5 and R2-R10 all denied the allegation.
Allegation: Staff do not ensure the resident is provided with breakfast, lunch, and dinner each day.
On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. Staff members (5 out of 5) and 9 out of 10 residents stated that staff ensure the residents are provided with breakfast, lunch, dinner, and snacks. Residents confirmed they receive three meals per day, and alternative food choices are offered. The facility provides a diverse range of food options, and if a resident requests a second serving, staff accommodates the request. R2-R10 stated they receive plenty of food to eat, and if they don't want to dine in the dining lounge, they can complete a tray service request. Staff will collect the request slip and deliver the meal to the resident's room. R1 stated that staff do not ensure residents are provided with breakfast, lunch, and dinner each day. LPA observed residents eating lunch and dinner and reviewed the food menus. LPA observed an ample supply of perishable and non-perishable food items. LPA observed staff serving meals during breakfast and lunch. LPA also reviewed the resident's tray service form. S1-S5 and R2-R10 all denied the allegation.

See continued LIC9099-C page 3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20250421123647

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: 08/05/2025

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

Continued LIC9099-C page 3

Allegation: Staff do not ensure adequate care and supervision is provided to residents
On 04/28/2025, between 10:00 a.m. and 11:30 a.m., the Department interviewed two staff members #1 and #5 (S1-S5), regarding the allegation. S2 stated that a resident reported another resident had entered their room; however, there were no witnesses to the incident, and a review of the facility’s surveillance cameras did not reveal any unauthorized entry. Maintenance checked the resident's door and confirmed it was in operable condition. S1 and S5 explained that care staff conduct Wellness checks on residents every two hours. All residents have pendants and call buttons to alert staff if they need assistance. Staff confirmed that no unauthorized individuals were observed entering residents’ rooms. S1 and S5 stated residents’ doors remain locked, and each resident has a personal key to their own room. S1-S5 states the facility currently has about 93 staff members employed and is fully staffed, and that residents are receiving appropriate care, supervision, and assistance with their daily needs. Both interviewed staff (5 out of 5) confirmed the facility is sufficiently staffed and denied the allegation.

On April 28, 2025, between 11:45 a.m. and 12:00 p.m., the Department reviewed the facility’s Personnel Report (LIC 500), which listed the following staff positions: Executive Director; Human Services Director; Vice President of Operations; Business Office Manager; Human Resources Director; Resident Care Director; ALW Coordinator; 4 Licensed Vocational Nurses (LVNs); 2 Community Liaisons; 2 Maintenance Staff; 4 Cooks; 5 Kitchen Staff; 4 Food Servers; 2 Dishwashers; 6 Dietary Aides; 9 Medication Technicians; 7 Memory Care Caregivers; 1 Memory Care Activity Director; 2 Activities Assistants; 25 Caregivers; 7 Housekeepers; 4 Receptionists; and 1 Driver a total number of employees listed: 93, confirmed the facility is adequately staffed. On April 20, 2025, there were 10 staff members on the night shift at 9:30 p.m. No incident reports were filed regarding the allegation. None of the caregivers reported witnessing anything, and nothing was documented in the residents' records.

See continued LIC9099-C page 4

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20250421123647

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: 08/05/2025

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

Continued LIC9099-C page 4

On April 28, 2025, between 12:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with ten residents #1-#10 (R1–R10) regarding the allegation of inadequate care and supervision. 9 out of 10 residents stated that the facility is adequately staffed and confirmed they are receiving the necessary care and supervision. 9 out of 10 also stated that staff are consistently present every shift. 1 out of 10 residents expressed concern about staffing and did not feel care and supervision were adequate. 9 out of 10 residents reported that they were happy living at the facility and had no problems or complaints. The majority of residents (9 out of 10) denied the allegation and stated that their daily needs were being met.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. 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 deemed unsubstantiated.

There were no deficiencies cited.

An exit interview was conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4