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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 05/01/2026
Date Signed: 05/01/2026 03:52:11 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, 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
04/03/2026 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20260403114442
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:SUZETTE JOHNSONFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 243DATE:
05/01/2026
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Executive Director Suzette JohnsonTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Staff gave resident the wrong medication.
INVESTIGATION FINDINGS:
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On 05/01/26 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director as the purpose of today’s visit was explained.

The investigation consisted of the following: On 04/09/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, pre placement appraisal dated: 07/20/21 Physicians report dated:12/09/25, Physicians orders, Medication Administration Record (MAR) for 03/2026- 04/2026, service plan dated: 09/12/25, and facility notes dated: 07/2023-03/2026. On 04/09/26 from 11:00 am- 12pm LPA conducted Interviews with Staff #1-4 (S1-S4), and on 04/09/26 from 1pm- 2:30pm LPA conducted interviews with residents # 1-10 (R1-R10). On 04/22/26 LPA Villegas conducted a review of documents obtained. On 04/22/26 The Department addressed similar complaint allegation which was found to be unsubstantiated. On 05/01/26 LPA Villegas conducted a medication administration records review.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
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-20260403114442
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: 05/01/2026
NARRATIVE
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Allegation: Staff gave a resident the wrong medication.

It is alleged that facility staff gave a resident in care medication for two days that were prescribed to a different resident in care. On 04/09/26 from 11:00 am- 12pm LPA conducted Interviews with S1-S4 regarding the allegation above. 4 of the 4 staff interviewed denied the above allegation. Per 4 of 4 of the staff interviewed, residents with the same or similar name staff are verifying birth dates prior to administering medications. Additionally, 2 of the 4 staff interviewed reported that the facilities electrical medication administration record (EMAR) has some of the resident’s pictures which are also used to confirm that the medication is being administered to the correct resident. On 04/09/26, 4 of the 4 staff interviewed reported that a supervisor is notified if a medication error occurs. On 04/09/26 from 1pm- 2:30pm LPA conducted interviews with R1-R10 regarding the allegation above. 7 of the 10 residents interviewed denied the allegation above. 1 of the 10 residents interviewed reported managing their own medications therefore they have no knowledge of the allegation above. 2 of the 9 residents interviewed confirmed the allegation above and report they made the staff aware of the error. On 04/22/26 LPA Villegas conducted a review of documents obtained, per preplacement appraisal dated: 07/20/21, Physicians report dated:12/09/25, and Service plan dated: 09/12/25 R1 requires assistance with medication and R1 cannot store nor administer their own medications. On 04/22/26 The Department addressed similar complaint allegation which was found to be unsubstantiated. 05/01/26 LPA Villegas conducted a medication review and observed all medications to be accounted for and documented on EMAR.

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 not provided.

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

DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2