197608029-3-19-2026-11-AS-UCOL-DTNNF2-20260501102443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 03/19/2026
Date Signed: 03/19/2026 12:50:28 PM

Substantiated

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
02/18/2026 and conducted by Evaluator Jose Anguiano

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20260218190506

FACILITY NAME:	VISTA DEL MAR SENIOR LIVING		FACILITY NUMBER:	197608029
ADMINISTRATOR:	SUZETTE JOHNSON		FACILITY TYPE:	740
ADDRESS:	3360 MAGNOLIA AVENUE		TELEPHONE:	(562) 595-1559
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	300	CENSUS: 235	DATE:	03/19/2026
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Suzette Johnson		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Lack of care and supervision

INVESTIGATION FINDINGS:

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On 03/19/2026, at approximately 11:00 AM, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent visit to deliver findings. LPA met with the Administrator Suzette Johnson.

The investigation consisted of the following: LPA toured the memory care unit, conducted interviews with six staff (S1–S6) and seven family witnesses (W1–W7), and reviewed records including the personnel report, staff roster, February memory care staffing schedule, staff contact information, grouping sheet, incident reports, resident progress notes, physician discharge note, plan of operation, and registry staff schedule.

The investigation revealed the following regarding the allegation: “Lack of care and supervision” It is being alleged that staff failed to provide adequate supervision, resulting in a resident with dementia sustaining an unwitnessed fall during the night with no staff awareness of when or how the fall occurred.

Please see (LIC9099-C) for report continuation.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

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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Citations on this Visit Report are Under Appeal!

Control Number 11-AS-20260218190506

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type B 03/26/2026 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.	1 2 3 4 5 6 7	Licensee agreed to submit a plan of correction to LPA Jose Anguiano at Jose.Anguiano@dss.ca.gov by due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews, observations, and records review, the licensee failed to ensure sufficient staffing to meet residents needs during overnight hours, resulting in an unwitnessed fall and a pattern of unwitnessed falls where staff were unaware of when or how incidents occurred, posing an potential health and safety risk 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.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20260218190506

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: 03/19/2026

NARRATIVE

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Observations revealed the following: The memory care unit has a spread layout and houses approximately 35 residents, including residents requiring incontinence care and identified as fall risks. Staff reported grouping residents in a common area for visibility. At the time of the visit, approximately 4–5 staff were present. Based on the layout and resident care needs, this level of staffing may limit the ability to provide continuous supervision, particularly during overnight hours. Interviews conducted revealed the following: Staff (S1–S5) reported the fall was unwitnessed and discovered during morning rounds, and staff were unable to determine when or where the fall occurred. Staff (S1) reported four staff were scheduled; however, only three staff were present on the night shift due to staffing changes. Staff (S2–S3) confirmed three staff were assigned to the nocturnal shift. Staff (S6) reported that three staff typically care for approximately 35 memory care residents during night shift and stated this may not be sufficient to meet resident care needs. Witnesses (W1–W5) reported concerns regarding night supervision, staffing levels, and prior unwitnessed falls. Witnesses (W6–W7) reported no concerns. Records review revealed the following: Review of the February 2026 staffing schedule confirmed that three staff, including registry staff, were assigned to the overnight shift on 02/13/2026–02/14/2026. Records confirmed the resident sustained an injury consistent with a fall that occurred overnight. Documentation did not identify the time or circumstances of the fall and did not demonstrate staff awareness at the time of the incident. Nursing notes indicate limited information was available from the overnight shift regarding the incident. Review of incident reports and resident records identified a pattern of unwitnessed falls in February 2026, including incidents on or about 02/06/2026, 02/10/2026, and 02/14/2026, where residents were found on the floor with injuries during morning hours. Documentation consistently indicated staff were unaware of when or how the falls occurred. While appropriate medical care was provided after discovery, records do not demonstrate effective overnight monitoring.

Based on the evidence gathered, interviews conducted, observations, and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8. A citation is issued on the attached (LIC-9099D). An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

LIC9099 (FAS) - (06/04)

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