Inspection Report Summary
Most inspections of Vista Del Mar Senior Living Facility found no deficiencies, with many complaint investigations unsubstantiated, indicating generally consistent compliance with care and safety standards. The most recent report from September 24, 2025, cited two Type A deficiencies involving an unauthorized staff member and improper water temperatures, both posing immediate health and safety risks. Earlier reports showed some serious issues, including substantiated deficiencies related to medication management, fall risk supervision, and personal rights violations, but these were isolated and not recent. The facility has demonstrated improvement over time, with the latest annual inspection showing fewer and more contained deficiencies compared to past substantiated complaints involving pressure injuries, pest control, and medication errors. Overall, while some serious concerns have occurred, recent inspections suggest the facility is addressing these issues and maintaining better compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
84% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 252
Capacity: 300
Deficiencies: 2
Date: Sep 24, 2025
Visit Reason
An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements for the Vista Del Mar Senior Living Facility.
Findings
The facility was found to be generally compliant with licensing requirements, including proper record keeping, medication storage, and fire safety measures. However, two Type A deficiencies were cited related to staff criminal record clearance and water temperature maintenance.
Deficiencies (2)
Staff #7 is not associated with the facility, posing an immediate health, safety, or personal rights risk to persons in care.
Water temperatures in bedrooms 119, 135, 137, 217, and ML22 were observed to not be within the required range of 105°F to 120°F, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Number of staff records reviewed: 6
Number of resident records reviewed: 10
Number of medication administration records reviewed: 10
Facility capacity: 300
Current census: 252
Plan of Correction Due Date: Sep 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Executive Director | Met with Licensing Program Analysts during inspection and named in plan of correction |
| Lizeth Villegas | Licensing Program Analyst | Conducted inspection and authored report |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 252
Capacity: 300
Deficiencies: 0
Date: Sep 17, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to gather additional information regarding allegations that staff do not ensure residents' dietary care plans are followed, residents are provided with meals daily, and adequate care and supervision are provided.
Complaint Details
The complaint investigation was triggered by allegations received on 04/21/2025 concerning dietary care plan adherence, meal provision, and adequate care and supervision. The allegations were found unsubstantiated based on interviews, observations, and record reviews.
Findings
The investigation found that the allegations were unsubstantiated. Staff and most residents confirmed that dietary care plans are followed, residents receive three meals daily, and adequate care and supervision are provided. Surveillance footage and facility records did not support the allegations.
Report Facts
Staff members interviewed: 5
Residents interviewed: 10
Facility staff employed: 93
Night shift staff: 10
Residents confirming adequate care: 9
Residents denying allegations: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittney Buchannan | Executive Director | Met with Department during investigation and named in findings |
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 250
Capacity: 300
Deficiencies: 0
Date: Sep 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-09-04 regarding staff threatening residents, staff not preventing resident smoking in rooms, and staff not preventing resident threats between residents.
Complaint Details
The complaint involved allegations that staff were threatening residents, staff did not prevent residents from smoking in their rooms, and staff did not prevent a resident from threatening another resident. Interviews with 11 residents, 7 staff members, and a witness were conducted. Most denied the allegations; one resident confirmed smoking occurred but no evidence was found, and one resident confirmed a threat occurred but police were not called. The overall conclusion was that there was not a preponderance of evidence to substantiate the allegations, thus the complaint was unsubstantiated.
Findings
The investigation included interviews with residents, staff, and a witness, as well as review of relevant documents. The allegations were found to be unsubstantiated due to lack of sufficient evidence, with most residents and staff denying the allegations and no safety concerns identified.
Report Facts
Residents interviewed: 11
Staff interviewed: 7
Facility capacity: 300
Facility census: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Administrator | Met with Licensing Program Analyst during investigation |
| Lizeth Villegas | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Janae Hammond | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 250
Capacity: 300
Deficiencies: 0
Date: Aug 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate the allegation that staff were not properly addressing pest infestation in the facility.
Complaint Details
The complaint alleged that Resident #1 was facing a vermin infestation in their room and that staff were not adequately addressing the issue. Interviews with staff and residents, review of pest control service agreements and logs, and inspection of the facility found no pest infestation or bites. Resident #1 restricted staff access to their room, complicating intervention efforts. The allegation was unsubstantiated.
Findings
The investigation included interviews, record reviews, and facility inspection. The Department found no evidence to support the allegation of pest infestation or inadequate staff response. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 300
Census: 250
Pest control treatments per month: 40
Staff interviewed: 6
Residents interviewed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director | Met with Licensing Program Analyst during investigation and named in report |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 250
Capacity: 300
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that facility staff did not provide adequate food service to a resident in care.
Complaint Details
The complaint alleged that the facility kitchen did not provide lunch to go when requested. Interviews with staff denied the allegation, stating that packed meals were prepared and available, though not always picked up by the resident. The admission agreement did not document a requirement to provide packed meals. The allegation was unsubstantiated.
Findings
The investigation included interviews with the resident and staff, and a review of relevant documents. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, despite some concerns raised by the resident.
Report Facts
Complaint Control Number: 11-AS-20250811140929
Capacity: 300
Census: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Lizeth Villegas | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 250
Capacity: 300
Deficiencies: 0
Date: Aug 14, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-06-25 regarding resident falls and medical attention concerns at the facility.
Complaint Details
The allegations investigated were: 1) Resident fell due to staff neglect resulting in injury, and 2) Staff did not seek medical attention for the resident. Both allegations were unsubstantiated based on interviews and record reviews.
Findings
The investigation found both allegations unsubstantiated after interviews with residents, staff, and witnesses, and review of relevant records. No deficiencies were cited.
Report Facts
Resident interviews: 10
Staff interviews: 9
Witness interviews: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Executive Director | Met with Licensing Program Analyst during investigation and named in report |
| Socorro Leandro | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ulysses Coronel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 250
Capacity: 300
Deficiencies: 0
Date: Aug 12, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff were not properly addressing pest infestation in the facility.
Complaint Details
The complaint alleged that a resident had bugs crawling on their body and face at night. Interviews with residents and staff, review of pest control logs and communication notes were conducted. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that while some residents reported observing pests and having their rooms treated, others denied the allegation. Staff denied the allegation and reported that one resident refused cleaning services and threatened staff. Pest control logs showed regular treatment of bedrooms and common areas. There was insufficient evidence to substantiate the allegation, so it was deemed unsubstantiated.
Report Facts
Residents interviewed: 9
Staff interviewed: 5
Capacity: 300
Census: 250
Bedrooms treated weekly: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Executive Director | Met with Licensing Program Analyst during investigation |
| Lizeth Villegas | Licensing Program Analyst | Conducted complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 247
Capacity: 300
Deficiencies: 0
Date: Aug 6, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2025-07-14 regarding allegations about bathroom repair, posting of required notices, and resident freedom to leave their room.
Complaint Details
The complaint included three allegations: 1) Licensee did not ensure bathroom was in good repair; 2) Licensee did not ensure required notices were visibly posted; 3) Staff did not allow resident to leave their room. After interviews with staff, residents, and review of records and observations, all allegations were found to be unsubstantiated.
Findings
The investigation found no evidence to support the allegations. The bathroom was found to be in good repair, required notices were visibly posted in the facility, and residents were not restricted from leaving their rooms except for isolation due to COVID. Therefore, all allegations were unsubstantiated.
Report Facts
Staff interviewed: 10
Residents interviewed: 9
Facility capacity: 300
Facility census: 247
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Administrator | Met during inspection and involved in interviews regarding complaint allegations |
| Zina Brown | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 250
Capacity: 300
Deficiencies: 0
Date: Aug 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2025-04-21 regarding dietary care plan adherence, provision of meals, and adequacy of care and supervision at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to follow residents' dietary care plans, failure to provide three meals daily, and inadequate care and supervision. Interviews with staff and residents, review of records, and observations did not support these allegations. The facility was found to be adequately staffed with 93 employees, and residents reported satisfaction with care and meals.
Findings
The investigation found that the majority of staff and residents denied the allegations. Observations and record reviews confirmed that residents received well-balanced meals according to dietary plans, and the facility was adequately staffed with proper care and supervision. There was insufficient evidence to substantiate the complaints, and no deficiencies were cited.
Report Facts
Capacity: 300
Census: 250
Staff Count: 93
Resident Interviews: 10
Staff Interviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Administrator / Executive Director | Met with during the investigation and named in the report |
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 250
Capacity: 300
Deficiencies: 0
Date: Jul 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-07-14 regarding allegations about bathroom repair, posting of required notices, and resident freedom to leave their room.
Complaint Details
The complaint investigation addressed three allegations: 1) bathroom not in good repair, 2) required notices not visibly posted, and 3) staff did not allow resident to leave their room. After interviews with staff, residents, and the administrator, observations, and records review, all allegations were found to be unsubstantiated.
Findings
The investigation found no evidence to support the allegations. The bathroom was observed to be in good repair, required notices were visibly posted in the facility, and residents were not restricted from leaving their rooms except for isolation protocols. Therefore, all allegations were unsubstantiated.
Report Facts
Capacity: 300
Census: 250
Staff interviewed: 10
Residents interviewed: 9
Work order date: Jun 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Zina Brown | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 250
Capacity: 300
Deficiencies: 0
Date: Jul 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff were not safeguarding residents' belongings, specifically concerning theft of money from a resident.
Complaint Details
Allegation: Staff are not safeguarding resident's belongings. One resident reported missing money twice but did not report it to staff. Interviews with 9 of 10 residents and 6 of 6 staff denied the allegation. Review of resident files and theft records showed no reported losses. The allegation was unsubstantiated due to lack of evidence.
Findings
The investigation included interviews with residents and staff, and a review of relevant records. Most residents and all staff denied the allegations. One resident confirmed missing money but had not reported it. The investigation found no preponderance of evidence to substantiate the complaint, and the allegation was deemed unsubstantiated.
Report Facts
Capacity: 300
Census: 250
Resident interviews: 10
Staff interviews: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director | Met with Licensing Program Analyst during investigation |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 250
Capacity: 300
Deficiencies: 0
Date: Jul 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-12-09 regarding a resident sustaining an unexplained fracture and staff not seeking timely medical attention.
Complaint Details
The complaint involved allegations that a resident sustained an unexplained fracture and that staff did not seek medical attention in a timely manner. Interviews with staff and residents denied the allegations. Medical records showed the resident had a history of osteopenia and prior fractures. The resident refused hospital evaluation after a fall. The investigation concluded the allegations were unsubstantiated due to lack of sufficient evidence.
Findings
The investigation included interviews with staff and residents, review of medical and incident records, and found no preponderance of evidence to substantiate the allegations. The resident had a history of osteopenia and prior fractures, and staff and residents denied the allegations. The complaint was determined to be unsubstantiated.
Report Facts
Facility capacity: 300
Resident census: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director | Met with during investigation and named in report |
| Lizeth Villegas | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 252
Capacity: 300
Deficiencies: 0
Date: Jul 10, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit following a complaint received on 2025-06-25 alleging that staff did not keep the facility free of rodents.
Complaint Details
The complaint alleged that staff did not keep the facility free of rodents. Interviews revealed most staff and residents did not agree with the allegation. Records showed an active pest control contract with monthly treatments. The allegation was unsubstantiated.
Findings
The investigation included interviews with staff and residents, inspections of resident rooms, and review of pest control service records. No live rodents were observed, and pest control measures were confirmed to be in place with monthly service contracts. The allegation was found to be unsubstantiated due to insufficient evidence.
Report Facts
Staff interviewed: 10
Resident rooms inspected: 10
Residents interviewed: 11
Residents census: 252
Facility capacity: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Anguiano | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Suzette Johnson | Administrator | Facility administrator met during investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 252
Capacity: 300
Deficiencies: 0
Date: Jul 3, 2025
Visit Reason
An unannounced complaint investigation was conducted on 07/03/2025 following allegations received on 06/26/2025 regarding medication disposal, safeguarding, administration, care plan adherence, hygiene, feeding, and resident treatment at Vista Del Mar Senior Living Facility.
Complaint Details
The complaint included nine allegations: staff not disposing of medications, not safeguarding medications, not administering medications, not following care plans, leaving residents in soiled diapers, not bathing residents, not feeding residents, and teasing residents. All allegations were investigated and found unsubstantiated.
Findings
The investigation included interviews with staff and residents, review of records, and facility tours. All allegations were found to be unsubstantiated based on interviews, documentation, and observations. No deficiencies were cited during the visit.
Report Facts
Staff denying allegations: 8
Residents denying allegations: 12
Facility capacity: 300
Facility census: 252
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Administrator | Met during investigation and named in report |
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation |
| Ulysses Coronel | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 252
Capacity: 300
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not keep the facility free of rodents.
Complaint Details
The complaint was unsubstantiated after investigation. Although rodent droppings were found, there was insufficient evidence to prove the allegation that staff did not keep the facility free of rodents.
Findings
During the investigation, rodent droppings were observed in the kitchen area, but no live rodents were found. The facility had a valid pest control service contract with monthly treatments. Based on evidence gathered, the allegation was found to be unsubstantiated.
Report Facts
Capacity: 300
Census: 252
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Anguiano | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Suzette Johnson | Administrator | Facility administrator met during the investigation and received the complaint report |
| Sidonia Cordis | Resident Care Director | Met with the Licensing Program Analyst during the investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 252
Capacity: 300
Deficiencies: 1
Date: Jul 2, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation conducted due to complaint number 11-AS-2025062515023.
Complaint Details
The visit was triggered by complaint 11-AS-2025062515023. The deficiency cited was related to lack of fitted bed sheets on R1's bed. The deficiency is under appeal.
Findings
A deficiency was observed in room 316 where resident R1's bed had no fitted bed sheets, violating California Code of Regulations Title 22, Division 6, Chapter 8. Plans of correction were developed during the exit interview.
Deficiencies (1)
R1’s bed had no fitted bed sheets.
Report Facts
Capacity: 300
Census: 252
Plan of Correction Due Date: Jul 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director/Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Socorro Leandro | Licensing Program Analyst | Conducted the inspection and authored the report |
| Ulysses Coronel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 252
Capacity: 300
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident sustained an unexplained injury while in care.
Complaint Details
Allegation: Resident sustained an unexplained injury while in care. The investigation found no substantiation as residents and staff denied the allegation, incident reports and fall risk assessments were documented and communicated, and the resident denied the allegation stating they are clumsy and declined medical attention after falls.
Findings
The investigation included interviews with residents and staff, review of resident records and incident reports, and telephone interviews. The allegation was unsubstantiated due to lack of preponderance of evidence, with residents and staff denying the allegation and documentation showing incident reports and fall risk assessments were properly handled.
Report Facts
Capacity: 300
Census: 252
Incident reports: 3
Fall risk assessments: 3
Residents interviewed: 9
Staff interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Suzette S. Johnson | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 252
Capacity: 300
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation conducted to address allegations that staff did not prevent a resident from engaging in inappropriate behaviors and that staff were not providing a comfortable environment for the resident.
Complaint Details
The complaint alleged that a resident's roommate was engaging in inappropriate behaviors, including interfering with the resident's oxygen tank, and that the environment was uncomfortable due to the roommate and family members turning off the air conditioning. Interviews with staff and residents did not substantiate these allegations. The facility initiated a room change for the resident to resolve the concerns. The complaint was determined to be unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff and residents denied knowledge of the alleged issues, and the facility took steps to address the resident's concerns by creating a work order to move the resident to a new room. No deficiencies were cited.
Report Facts
Capacity: 300
Census: 252
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director | Met with Licensing Program Analyst during the investigation and participated in exit interview |
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 247
Capacity: 300
Deficiencies: 0
Date: May 30, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation following a complaint received on 2025-04-30 regarding improper management of a resident's catheter care.
Complaint Details
The complaint alleged that staff did not ensure resident's catheter was regularly emptied and cleaned. Interviews with 10 residents and 11 staff all denied the allegation. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included interviews with residents and staff, review of reports, and a facility tour. The allegation that staff did not properly manage resident catheter care was found to be unsubstantiated due to insufficient evidence.
Report Facts
Residents interviewed: 10
Staff interviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Administrator | Met with during investigation and exit interview |
| Troy Watson | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 251
Capacity: 300
Deficiencies: 1
Date: May 16, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations including a resident sustaining a fracture due to lack of care from staff and staff refusing to accept a resident back following a hospital visit.
Complaint Details
The complaint investigation was substantiated for the allegation that a resident sustained a fracture due to lack of care from staff. The allegation that staff refused to accept the resident back following a hospital visit was unsubstantiated.
Findings
The investigation substantiated that a resident sustained a cervical spine fracture due to multiple unwitnessed falls from a wheelchair and lack of a fall risk management plan. Another allegation that staff refused to accept the resident back after hospital discharge was unsubstantiated due to insufficient evidence.
Deficiencies (1)
Failed to provide a fall risk management plan and adequate supervision for a high fall risk resident, resulting in multiple falls and a cervical spine fracture.
Report Facts
Capacity: 300
Census: 251
Civil penalty: 500
Plan of Correction Due Date: May 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Executive Director | Named in relation to the investigation and interviews |
| Sideonis Cordis | Resident Care Director | Met with department during investigation |
| Suzette Johnson | Executive Director who received exit interview and report | |
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 251
Capacity: 300
Deficiencies: 1
Date: May 16, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-11-19 alleging that facility staff did not dispense medications as prescribed and that a resident developed a pressure injury due to staff neglect.
Complaint Details
The complaint investigation was substantiated for the allegation that facility staff did not dispense medications as prescribed, with evidence showing a resident did not receive their weekly medication dosage due to medication being misplaced by staff. The allegation that a resident developed a pressure injury due to staff neglect was unsubstantiated based on interviews and record reviews.
Findings
The investigation substantiated the allegation that facility staff did not dispense medications as prescribed, citing one deficiency related to medication management. The allegation regarding the resident developing a pressure injury due to staff neglect was found to be unsubstantiated with no deficiencies cited.
Deficiencies (1)
Failure to maintain a record of dosages of medications as required, evidenced by a resident's medication administration record (MAR) in disrepair posing potential health and safety risks.
Report Facts
Estimated Days of Completion: 90
Medication administrations in September 2024: 19
Residents interviewed: 10
Staff interviewed: 5
Residents interviewed: 4
Staff interviewed: 2
Total staff: 105
Total residents: 238
Residents disagreeing with pressure injury allegation: 9
Staff disagreeing with pressure injury allegation: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director | Met with Licensing Program Analyst during investigation and exit interviews |
| Mario Leon | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 250
Capacity: 300
Deficiencies: 0
Date: May 14, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not ensure resident's catheter care was properly managed.
Complaint Details
The allegation was that staff did not ensure that resident’s catheter was regularly emptied and cleaned. Interviews with 10 residents and 11 staff found no issues reported. Based on interviews and observations, there was insufficient evidence to support the allegation, resulting in an unsubstantiated finding.
Findings
The investigation included interviews with residents and staff and review of records. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.
Report Facts
Residents interviewed: 10
Staff interviewed: 11
Facility census: 250
Facility capacity: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Administrator | Met with during inspection and exit interview |
| Troy Watson | Licensing Program Analyst | Conducted complaint investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 246
Capacity: 300
Deficiencies: 0
Date: May 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not provide comfortable water temperature for residents and did not keep residents' rooms free from pests.
Complaint Details
The complaint included two allegations: 1) staff failing to provide comfortable water temperature, and 2) staff not keeping residents' rooms free from pests. Both allegations were found unsubstantiated after interviews, inspections, and document reviews.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Staff and residents confirmed access to hot water despite boiler issues, and pest control measures were active and effective with no pest activity observed during the inspection.
Report Facts
Resident census: 246
Total capacity: 300
Pest control treatments: 40
Staff interviewed: 5
Residents interviewed: 10
Water temperature range: 105.1
Water temperature range: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director | Met with during inspection and exit interview |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 246
Capacity: 300
Deficiencies: 0
Date: Apr 28, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff did not ensure residents' dietary care plans were followed, residents were not provided with all meals daily, and that adequate care and supervision were not provided.
Complaint Details
The complaint included allegations that staff did not ensure residents' dietary care plans were followed, residents were not provided with breakfast, lunch, and dinner each day, and that adequate care and supervision were not provided. Interviews with staff and residents mostly denied these allegations. Surveillance and facility checks found no evidence of unauthorized room entry. The complaint was deemed unsubstantiated.
Findings
The investigation found that staff and most residents confirmed dietary care plans were followed and meals were provided as required. The facility was adequately staffed and residents received appropriate care and supervision. There was insufficient evidence to substantiate the allegations, and no deficiencies were cited.
Report Facts
Staff employed: 93
Residents interviewed: 10
Staff interviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Executive Director | Met with during investigation and named in report |
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 242
Capacity: 300
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that a resident had unknown exposure to fentanyl while in care.
Complaint Details
The complaint alleged that a resident was exposed to fentanyl while in care. The investigation found no evidence or witness statements supporting the allegation. Staff and residents denied knowledge of illegal drug use in the facility. Medical records showed the resident tested positive for fentanyl during hospitalization, but this was likely a false-positive due to psychotropic medications. The allegation was determined to be unsubstantiated.
Findings
The investigation included interviews with staff, residents, and a witness, as well as review of medical and facility records. The allegation was found to be unsubstantiated due to insufficient evidence, with staff denying access to fentanyl and medical records indicating possible false-positive test results.
Report Facts
Capacity: 300
Census: 242
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Administrator | Met during investigation and named in findings |
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation |
| Olivia Spindola | Investigation Bureau Investigator | Assigned to investigate the complaint |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 240
Capacity: 300
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that the facility memory care unit is not properly staffed, which purportedly led to resident falls.
Complaint Details
The complaint alleged insufficient staffing in the memory care unit causing resident falls. Interviews with staff and residents, and review of staffing schedules showed adequate staffing levels with 6 staff in the morning, 4 in the evening, and 2 at night for 42 memory care residents. The allegation was unsubstantiated.
Findings
The investigation included interviews with staff and residents, review of staff time cards and schedules, and a facility tour. No health or safety concerns were observed, and the allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Memory care residents: 42
Staff morning shift: 6
Staff evening shift: 4
Staff night shift: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Executive Director | Met with Licensing Program Analyst during investigation |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 239
Capacity: 300
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that facility staff did not provide a resident with a bedroom chair.
Complaint Details
The complaint alleged that residents were not provided a chair in their room per Title 22 regulations. Interviews with 4 staff and 10 residents found 9 residents and all staff denied the allegation. The facility provided required furnishings including chairs, and some residents brought their own furniture. The allegation was determined to be unsubstantiated due to insufficient evidence.
Findings
The investigation included interviews with staff and residents and a tour of multiple resident rooms. The majority of staff and residents denied the allegation, and all observed rooms had the required furnishings. There was insufficient evidence to substantiate the complaint, and no citations were issued.
Report Facts
Capacity: 300
Census: 239
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director | Met with during the complaint investigation and named in the report |
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 239
Capacity: 300
Deficiencies: 0
Date: Jan 31, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-01-14 regarding medication storage, pest control, medication management, and falsification of medication administration records.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included improper medication storage, presence of insects, mismanagement of residents' medication, and falsification of medication administration records. Interviews with staff and residents, document reviews, and observations did not support the allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Medication was observed to be stored properly, the facility was free of pests at the time of inspection with ongoing pest control measures, medication management practices were appropriate, and no discrepancies were found in medication administration records.
Report Facts
Capacity: 300
Census: 239
Number of residents interviewed: 10
Number of staff interviewed: 5
Pest control reports reviewed: 2
Medication in-service dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Executive Director | Met with during investigation and interviewed regarding allegations |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 243
Capacity: 300
Deficiencies: 0
Date: Dec 31, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not seek medical attention for a resident in a timely manner and did not keep the resident's authorized person informed about incidents involving the resident.
Complaint Details
The complaint alleged that staff failed to seek timely medical attention for a resident who had a fall and failed to inform the resident's authorized person about incidents. Interviews with staff and residents, and review of incident reports and medical records, found no evidence to support these allegations. The complaint was determined to be unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff and residents denied the claims, and records showed the family was notified promptly about the resident's condition. No deficiencies were cited.
Report Facts
Facility capacity: 300
Census: 243
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director | Met during the investigation and named in the report |
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 243
Capacity: 300
Deficiencies: 0
Date: Dec 26, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff did not assist a resident with obtaining medical care, did not allow the resident to choose their care provider, and did not safeguard the resident's personal belongings.
Complaint Details
The complaint alleged that staff did not assist resident (R#1) with medical care, forced the resident to choose an in-house doctor, and failed to safeguard the resident's personal belongings. The investigation included interviews with the administrator, staff, and residents, and review of medical and admission records. The allegations were found to be unsubstantiated.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Interviews with the administrator, staff, and residents, as well as document reviews, indicated that the facility provides transportation assistance for medical appointments, does not force residents to change care providers, and safeguards residents' personal belongings.
Report Facts
Residents interviewed: 14
Staff interviewed: 9
Capacity: 300
Census: 243
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Executive Director | Met during investigation and provided statements regarding allegations |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 243
Capacity: 300
Deficiencies: 1
Date: Dec 20, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding the allegation that staff allowed a resident to leave the facility without supervision.
Complaint Details
The complaint alleged that staff allowed resident R1 to leave the facility without supervision. The allegation was substantiated after investigation, including interviews with staff, residents, and the responsible party, as well as review of records and incident reports.
Findings
The investigation found that resident R1, who has a dementia diagnosis and wandering behaviors, was able to leave the facility unassisted, which poses a potential health, safety, and personal rights risk. Staff and residents interviewed denied the allegation, but R1 confirmed leaving unassisted. The allegation was substantiated based on evidence including interviews, record reviews, and incident reports.
Deficiencies (1)
Personal Rights of Residents in All Facilities: Resident R1 with dementia was able to leave the facility unassisted, posing a potential health, safety, or personal rights risk.
Report Facts
Capacity: 300
Census: 243
Plan of Correction Due Date: Jan 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director | Named in relation to the allegation and investigation findings |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 242
Capacity: 300
Deficiencies: 1
Date: Dec 10, 2024
Visit Reason
The visit was conducted as a case management deficiencies visit to issue a citation observed during a complaint investigation related to a failure to report a resident fall incident.
Complaint Details
The visit was triggered by a complaint investigation, control number 11-AS-20241209092305. The deficiency was substantiated as the facility did not report the fall incident as required.
Findings
The facility failed to report an incident where resident #1 sustained a fall on 12/01/2024 within the required 7 days to Community Care Licensing, violating Title 22 Reporting Requirements 87211(a)(1)(B).
Deficiencies (1)
Failure to submit a written report to Community Care Licensing within 7 days for resident #1's fall incident.
Report Facts
Deficiency due date: Dec 13, 2024
Census: 242
Total Capacity: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Executive Director | Met during the visit and confirmed the incident date and failure to report |
| Lizeth Villegas | Licensing Program Analyst | Conducted the case management deficiencies visit |
| Janae Hammond | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report |
Inspection Report
Complaint Investigation
Census: 246
Capacity: 300
Deficiencies: 1
Date: Dec 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff did not respond to residents' calls for assistance.
Complaint Details
The complaint was substantiated. The allegation was that facility staff did not respond to residents' calls for assistance, specifically that staff did not respond to the call button. Interviews and observations supported this finding.
Findings
The investigation found the allegation substantiated based on observations and interviews, including a documented 22-minute delay in response to an emergency call via pull cord and an average response time of 5 minutes during testing of working pull cords. One deficiency related to maintenance and operation was cited.
Deficiencies (1)
Failure to maintain the facility in good repair, specifically ensuring residents' emergency pull cords are in working condition.
Report Facts
Residents interviewed: 14
Staff interviewed: 6
Deficiencies cited: 1
Estimated days for correction: 90
Response time observed: 22
Average response time: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director | Met with CCLD staff during investigation and exit interview; named in findings. |
| Mario Leon | Licensing Program Analyst | Conducted the complaint investigation. |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 246
Capacity: 300
Deficiencies: 0
Date: Nov 22, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-11-15 regarding pest control, cleanliness, and hot water availability at the facility.
Complaint Details
The complaint involved three allegations: 1) Staff do not ensure the facility is free from pests; 2) Staff do not ensure the facility is clean and sanitary; 3) Staff do not ensure resident has hot water. The investigation included interviews with staff and residents, facility tours, and document reviews. The allegations were found unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents provided mixed responses, facility tours and document reviews showed regular pest control treatments, daily and weekly cleaning schedules, and regular water temperature checks. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 300
Census: 246
Water temperature readings: 111.7
Water temperature readings: 113.6
Water temperature readings: 114.2
Water temperature readings: 116.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director | Met during inspection and involved in exit interview |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 247
Capacity: 300
Deficiencies: 0
Date: Nov 22, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following allegations that the facility was not free from pests and was not adequately cleaned.
Complaint Details
The complaint alleged that the facility had roaches throughout the building and in the Spa Room, and that staff did not ensure the facility was adequately cleaned. Interviews with staff and residents, observations, and record reviews found insufficient evidence to support these allegations. The complaint was determined to be unsubstantiated.
Findings
The investigation included interviews with staff and residents, review of pest control records, and facility tour. No evidence was found to substantiate the allegations; the facility was observed to be clean and pest-free, and pest control services were regularly provided.
Report Facts
Staff interviewed: 4
Residents interviewed: 10
Pest control service dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director | Met with during the investigation and named in the report |
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 243
Capacity: 300
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
The visit was an unannounced complaint investigation regarding allegations that staff were serving food that was not of good quality and that foods were not properly labeled.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included poor food quality and improper labeling of foods and drinks. Interviews with staff and residents mostly denied the allegations, and observations did not confirm the issues. Although some residents reported occasional concerns, there was insufficient evidence to substantiate the allegations.
Findings
The investigation found that the allegations were unsubstantiated. Interviews with staff, residents, and the Executive Director, as well as observations of the kitchen and dining areas, did not reveal evidence supporting the complaints. Some residents noted minor concerns about food quality and labeling, but overall no violations were confirmed.
Report Facts
Capacity: 300
Census: 243
Number of staff interviewed: 5
Number of residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette Johnson | Executive Director | Met with during investigation and named in interviews regarding allegations |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 243
Capacity: 300
Deficiencies: 0
Date: Oct 23, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff do not answer resident calls for assistance, do not ensure the facility is free from pests, and do not maintain the facility in good repair.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not answering calls for assistance, presence of pests such as roaches and bed bugs, and poor maintenance of air conditioning and refrigerators. Interviews with staff and residents, facility inspection, and document reviews did not support these allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff response times to resident calls were generally under 10 minutes, no pests were observed during inspection, and the facility was found to be in good repair with working air conditioning and refrigerators. Pest control services were regularly provided by Terminix.
Report Facts
Response times to resident calls: 6
Census: 243
Total capacity: 300
Staff interviewed: 8
Residents interviewed: 11
Pest control service dates: 84
Work order review period: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Executive Director | Met with during the investigation and exit interview |
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation |
| Perry Scott | Licensing Program Analyst | Assisted in conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 235
Capacity: 300
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations of staff neglect resulting in resident deaths and failure to prevent a resident from causing self-harm.
Complaint Details
The complaint involved two allegations: 1) Staff neglect resulted in the death of residents; 2) Staff did not prevent a resident from causing self-harm. The investigation included review of death reports, interviews with staff and hospice agencies, and review of incident reports. Both allegations were found unsubstantiated due to lack of evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Deaths of residents were confirmed to be due to end-stage illnesses with hospice involvement, and staff had no knowledge of the resident's intent to self-harm, thus could not prevent it. Both allegations were deemed unsubstantiated.
Report Facts
Resident deaths: 6
Facility capacity: 300
Facility census: 235
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sparkle Day | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Janie Acosta | Administrator | Facility administrator interviewed during investigation |
| Suzette Johnson | Resident Care Director | Interviewed during exit interview and investigation |
Inspection Report
Annual Inspection
Census: 235
Capacity: 300
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
The visit was an unannounced annual required inspection conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with regulations, including proper maintenance of staff, resident, and medication records, adequate safety measures such as fire drills and operational detectors, and well-maintained resident rooms and common areas. No discrepancies or deficiencies were noted.
Report Facts
Staff records reviewed: 8
Resident records reviewed: 10
Medication administration records reviewed: 10
Licensed capacity: 300
Current census: 235
Hospice waiver capacity: 50
Number of bedridden residents allowed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzette S. Johnson | Executive Director | Met with Licensing Program Analysts during inspection and participated in exit interview |
| Lizeth Villegas | Licensing Program Analyst | Conducted the inspection |
| Janae Hammond | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Capacity: 300
Deficiencies: 1
Date: Sep 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations that staff did not ensure a resident was allowed to leave the facility at any time with visitors and that staff did not ensure residents were allowed to have visitors.
Complaint Details
The complaint investigation was substantiated regarding the allegation that staff did not ensure resident R1 was allowed to leave the facility with visitors due to improper POA restrictions. The allegation that staff did not ensure residents were allowed to have visitors was unsubstantiated.
Findings
The investigation substantiated that facility staff violated a resident's personal rights by allowing a POA with authority limited to healthcare decisions to restrict the resident's right to leave the facility with visitors. Another allegation that staff did not ensure residents were allowed to have visitors was unsubstantiated due to lack of sufficient evidence.
Deficiencies (1)
Facility staff violated resident R1 personal rights by allowing a POA with authority only over healthcare decisions to restrict R1's right to leave the facility with visitors.
Report Facts
Facility capacity: 300
Plan of Correction due date: Sep 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Suzette Johnson | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Janie Acosta | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Capacity: 300
Deficiencies: 0
Date: Aug 22, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not ensure the facility was free from pests and did not adequately clean a resident's room.
Complaint Details
The complaint alleged that roaches were observed under a resident's bed and that the resident's room was not properly cleaned. Interviews with staff and residents, review of cleaning schedules, pest control invoices, and a tour of the resident's room did not confirm these allegations. The complaint was unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents reported regular cleaning and pest control measures, and no health or safety concerns were observed during the visit. The complaint was determined to be unsubstantiated.
Report Facts
Facility capacity: 300
Complaint control number: 11-AS-20240813145825
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
| Suzette Johnson | Executive Director | Interviewed during the investigation and exit interview |
| Janie Acosta | Administrator | Facility administrator mentioned in report header |
Inspection Report
Complaint Investigation
Census: 239
Capacity: 300
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff did not administer medication to a resident.
Complaint Details
The complaint alleged that staff did not administer medication to a resident. The investigation included interviews with staff and residents, review of medication administration records, and observations. The allegation was found to be unsubstantiated due to lack of sufficient evidence.
Findings
Based on interviews with staff and residents, observations, and review of medication administration records, there was insufficient evidence to substantiate the allegation that staff failed to administer medication. The Executive Director and staff denied the allegation, and medication availability was confirmed. The allegation was determined to be unsubstantiated and no deficiencies were cited.
Report Facts
Residents in memory care with Covid-19: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Espana | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named in report as Licensing Program Manager |
| Suzette Johnson | Administrator | Met with Licensing Program Analyst during inspection and received report copy |
| Janie Acosta | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 239
Capacity: 300
Deficiencies: 0
Date: Jul 19, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not prevent a resident from attacking another resident.
Complaint Details
The complaint alleged that resident #1 was physically assaulted by another resident and that staff failed to prevent the assault. The investigation included interviews with residents, staff, and family, as well as review of medical and incident reports. The allegation was found to be unsubstantiated due to lack of evidence.
Findings
The investigation found no sufficient evidence to corroborate the allegation of physical assault between residents. Interviews, record reviews, and observations indicated the allegation was unsubstantiated.
Report Facts
Number of residents present: 239
Total licensed capacity: 300
Number of prescribed medications for resident #1: 22
Number of medications with side effects causing skin issues: 13
Number of residents interviewed: 10
Number of staff interviewed: 4
Number of executive directors interviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Suzette Johnson | Executive Director | Met with Licensing Program Analyst during the investigation and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 240
Capacity: 300
Deficiencies: 0
Date: Jun 13, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-06-06 regarding admission agreements, transportation after medical appointments, and residents eating in their rooms.
Complaint Details
The complaint investigation addressed three allegations: 1) Staff did not provide a resident an admission agreement; 2) Staff did not pick up a resident after a medical appointment; 3) Staff prohibited a resident from eating in their room. All allegations were found to be unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to substantiate any of the three allegations. Interviews with residents, staff, and review of documents showed that admission agreements were provided, transportation policies were in place and followed, and residents were allowed to eat in their rooms.
Report Facts
Capacity: 300
Census: 240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Janie Acosta | Executive Director | Facility representative involved in interviews and exit interview |
| Sidonia Cordis | Resident Care Director | Interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 240
Capacity: 300
Deficiencies: 0
Date: Jun 13, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not seek medical attention for a resident and that facility staff failed to meet residents' needs.
Complaint Details
The complaint alleged that staff failed to obtain medication for resident #1 and failed to monitor the resident's blood pressure. Interviews with the Executive Director, staff, and residents, along with record reviews, did not support these allegations. The medication was not administered due to pharmacy delivery delays, and there was no doctor's order for blood pressure checks. The allegations were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with staff and residents, as well as medication and medical record reviews, did not reveal any discrepancies or violations. Therefore, the allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 300
Census: 240
Number of residents interviewed: 10
Number of staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Executive Director | Met with during investigation and named in findings |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 240
Capacity: 300
Deficiencies: 0
Date: Jun 13, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-05-30 alleging that a resident became ill due to the food served at the facility.
Complaint Details
The complaint alleged that Resident #1 became ill due to food served at the facility. Interviews with staff and residents, review of certifications, and observations of food handling and sanitation practices were conducted. The allegation was unsubstantiated as there was not a preponderance of evidence to support it.
Findings
The investigation included interviews, document reviews, and observations of kitchen and dining procedures. The allegation that staff did not ensure universal precautions were taken was found to be unsubstantiated due to insufficient evidence to prove the alleged violation.
Report Facts
Complaint control number: 11-AS-20240530104557
Number of residents interviewed: 10
Number of staff interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Executive Director | Met with during investigation and named in findings |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 240
Capacity: 300
Deficiencies: 0
Date: Jun 13, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-05-29 regarding multiple allegations including pest presence, unmet resident needs, safeguarding of personal items, inappropriate staff comments, laundry services, and room cleanliness.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included pests in the facility, failure to meet residents' needs, failure to safeguard personal items, inappropriate staff comments, unmet laundry needs, and unclean rooms. Interviews and document reviews did not support these allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews with staff, residents, and review of documents showed that pest control services were increased, residents' belongings were accessible, wheelchairs were properly labeled, staff treated residents respectfully, laundry services were provided as per agreements, and rooms were cleaned daily with weekly deep cleaning.
Report Facts
Facility capacity: 300
Census: 240
Pest control frequency: 3
Residents interviewed: 10
Staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Executive Director | Met with during investigation and provided information denying allegations |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 236
Capacity: 300
Deficiencies: 0
Date: Jun 5, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to ascertain the validity of multiple allegations received on 2024-06-04 regarding staff practices at Vista Del Mar Senior Living Facility.
Complaint Details
The complaint included allegations that staff did not allow residents to use a doctor of their choice, did not provide medication as prescribed, did not treat residents with dignity or respect, and did not respond timely to residents' calls for assistance. The investigation involved interviews with staff and residents, review of medical and medication records, and call logs. All allegations were found unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegations that staff did not allow residents to choose their doctor, did not provide medication as prescribed, did not treat residents with dignity or respect, or did not respond timely to residents' calls for assistance. All allegations were determined to be unsubstantiated.
Report Facts
Capacity: 300
Census: 236
Call response time: 12
Medication frequency: 2
Medication frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Administrator | Facility administrator met during investigation and named in report |
| Sparkle Day | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Manager overseeing the licensing program and report |
Inspection Report
Complaint Investigation
Census: 240
Capacity: 300
Deficiencies: 0
Date: May 24, 2024
Visit Reason
This was an unannounced complaint investigation visit conducted in response to a complaint received on 2022-07-29 alleging questionable death, resident falls, neglect, medication mishandling, and staff responsiveness issues at Vista Del Mar Senior Living Facility.
Complaint Details
The complaint included allegations of questionable death, resident fall, resident left on floor for extended period, failure to seek medical attention, medication mishandling, and staff not answering facility phones. After investigation, all allegations were found to be unsubstantiated due to insufficient evidence to prove violations.
Findings
The investigation found no substantiated violations related to the allegations. The resident's death was due to natural causes with no signs of foul play. Falls and response times were consistent with resident conditions and facility practices. Medication handling and staff responsiveness were found to be appropriate with no errors or neglect identified.
Report Facts
Facility capacity: 300
Census: 240
Medication orders: 7
Staff interviewed: 5
Residents interviewed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Janie Acosta | Executive Director | Facility representative met during the investigation and exit interview |
| Reggie Jones | Administrator | Facility administrator interviewed regarding allegations |
| Ryan Philippe | Investigator | Investigator from Community Care Licensing Investigation Branch who contributed to the investigation |
| J. Clark | Police Officer | Long Beach Police Department officer who observed resident R1's body and reported no signs of foul play |
Inspection Report
Follow-Up
Census: 240
Capacity: 300
Deficiencies: 0
Date: May 24, 2024
Visit Reason
The visit was a Case Management visit conducted during a subsequent complaint visit to review the Plan of Correction for a prior complaint.
Complaint Details
This visit was related to a subsequent complaint. The Plan of Correction from complaint 11-AS-20220718085319 was cleared after the Executive Director submitted proof of correction before the due date.
Findings
The Licensing Program Analyst cleared the Plan of Correction from the previous complaint and did not observe any deficiencies during this visit; therefore, no citations were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Executive Director | Met with Licensing Program Analyst during the visit and was given a copy of the Letter of Deficiency Citations Cleared. |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the Case Management visit and cleared the Plan of Correction. |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 240
Capacity: 300
Deficiencies: 0
Date: May 22, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 07/18/2022 alleging that a resident sustained multiple pressure injuries while in care.
Complaint Details
The allegation was that resident R1 developed stage 3 and/or stage 4 pressure injuries while in care. The investigation reviewed medical and home health records and interviewed staff, concluding there was no preponderance of evidence to prove the allegation. The complaint was found to be unsubstantiated.
Findings
The investigation found that the allegation was unsubstantiated as records and staff interviews indicated the resident did not develop stage 3 or 4 pressure injuries while in care. No deficiencies were cited.
Report Facts
Capacity: 300
Census: 240
Plan of Correction Due Date: May 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reggie Jones | Administrator | Named as facility administrator |
| Janie Acosta | Administrator | Met with during inspection and involved in health and safety check |
| Alfonso Iniguez | Evaluator | Conducted the complaint investigation |
| Ulysses Coronel | Licensing Program Manager | Oversaw complaint investigation |
| Jose Calderon | Licensing Program Analyst | Involved in complaint investigation and signed report |
| Benita Yates | Licensing Program Manager | Named in deficiency dismissal section |
Inspection Report
Complaint Investigation
Census: 245
Capacity: 300
Deficiencies: 0
Date: May 15, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to ascertain information regarding allegations that staff did not assist a resident with obtaining prescribed medication and did not administer medication as prescribed.
Complaint Details
The complaint involved allegations that staff did not assist a resident with obtaining prescribed medication and did not administer medication on time. Interviews with staff, residents, and file reviews were conducted. Staff and facility representatives denied the allegations. Medication Administration Records showed the resident refused medication seven times. The investigation concluded the allegations were unsubstantiated due to insufficient evidence.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur, resulting in the allegations being unsubstantiated.
Report Facts
Resident medication refusals: 7
Census: 245
Total capacity: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sparkle Day | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Janie Acosta | Administrator | Facility administrator mentioned in the report. |
Inspection Report
Complaint Investigation
Census: 245
Capacity: 300
Deficiencies: 0
Date: May 15, 2024
Visit Reason
An unannounced complaint investigation was conducted to ascertain the validity of an allegation that staff did not ensure prescribed medical equipment was provided to a resident in care.
Complaint Details
The complaint alleged that facility staff did not provide a prescribed medical bed to resident #1. Interviews with staff and a witness denied the allegation, and no prescription was found in the resident's records. Resident #1 refused to be interviewed. The allegation was unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegation that staff failed to provide prescribed medical equipment to the resident. Staff and witnesses denied the allegation, and no prescription for a hospital bed was found in the resident's file. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 300
Census: 245
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Administrator | Met with during the investigation |
| Sparkle Day | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 247
Capacity: 300
Deficiencies: 0
Date: Apr 11, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 04/04/2024 regarding facility disrepair, medication administration, staff respect, timely assistance, and communication barriers.
Complaint Details
The complaint investigation addressed five allegations: 1) Facility is in disrepair due to a damaged front door; 2) Staff did not administer residents' medication as prescribed; 3) Staff do not treat residents with respect; 4) Staff do not assist residents in a timely manner; 5) Staff cannot communicate effectively with residents due to language barriers. All allegations were found to be unsubstantiated.
Findings
The investigation found all allegations to be unsubstantiated based on interviews with residents, staff, and the administrator, review of training and documentation, and facility inspection.
Report Facts
Facility capacity: 300
Census: 247
Front door repair quote: 10000
Front door damage duration: 21
Call button response time: 5
Call button response time range: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Administrator | Interviewed regarding all allegations and facility operations |
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and interviews |
Inspection Report
Complaint Investigation
Census: 247
Capacity: 300
Deficiencies: 0
Date: Apr 9, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit triggered by an allegation that staff neglected a resident resulting in dehydration.
Complaint Details
The complaint alleged that the facility was not monitoring resident R1's fluid intake, causing dehydration. Staff and residents denied neglect, stating R1 was independent and received fluids regularly. The resident was hospitalized after showing confusion and lethargy. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegation of staff neglect resulting in dehydration. Interviews with staff and residents, as well as observations, indicated that the resident was independent and received adequate fluids and care. No deficiencies were cited.
Report Facts
Capacity: 300
Census: 247
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Administrator | Met with Licensing Program Analyst during the investigation and participated in exit interview |
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 232
Capacity: 300
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation initiated due to allegations received on 12/07/2021 regarding resident injuries, staff training, and vehicle maintenance at Vista Del Mar Senior Living.
Complaint Details
The complaint included three allegations: 1) Resident sustained multiple injuries while in care; 2) Facility staff are not properly trained; 3) Facility vehicle is not in good repair. All allegations were found unsubstantiated based on interviews, medical records, vehicle maintenance records, and staff training documentation.
Findings
The investigation found insufficient evidence to substantiate the allegations that a resident sustained multiple injuries while in care, that facility staff were not properly trained, and that the facility vehicle was not in good repair. Interviews, records, and observations supported that the resident had only minor injuries, staff were properly trained, and the vehicle was maintained.
Report Facts
Facility capacity: 300
Resident census: 232
Complaint receipt date: Dec 7, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Janie Acosta | Administrator | Facility administrator interviewed during investigation |
| Peter Zertuche | Investigator | Conducted initial investigation and report on resident injury allegation |
| James Bender | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 231
Capacity: 300
Deficiencies: 3
Date: Mar 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 08/31/2021 concerning resident care issues and facility conditions at Vista Del Mar Senior Living Facility.
Complaint Details
The complaint investigation was substantiated for neglect/lack of care and supervision related to a resident sustaining a pressure injury, presence of roaches in the facility, and failure to timely change a resident's soiled diaper. Allegations regarding medication dosage errors and food left in resident rooms were unsubstantiated.
Findings
The investigation substantiated three allegations: a resident sustained a Stage IV pressure injury while in care, the facility had roaches, and staff left a resident in a soiled diaper for an extended period. Two other allegations regarding medication dosage errors and food left in resident rooms were found unsubstantiated.
Deficiencies (3)
Facility retained Resident #1 with a Stage IV pressure injury (a prohibited health condition) until the resident passed away on 09/03/21.
Licensee failed to control roaches inside the facility for residents in care.
Licensee failed to provide an incontinence care log to support dates and times incontinent care was provided to Resident #1.
Report Facts
Capacity: 300
Census: 231
Deficiency count: 3
Plan of Correction Due Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Administrator | Met with during investigation and interviewed regarding allegations |
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 244
Capacity: 300
Deficiencies: 0
Date: Mar 19, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff did not prevent a resident from assaulting another resident.
Complaint Details
The complaint alleged that staff failed to prevent a resident from physically assaulting another resident. The investigation found no evidence to substantiate the allegation, with staff and residents reporting the incident involved a verbal confrontation and a remote control dispute, resulting in no injury.
Findings
The investigation included interviews with staff, residents, and a witness, as well as review of relevant documents. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, with most interviewed denying the incident or reporting no injury.
Report Facts
Capacity: 300
Census: 244
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Executive Director | Met with Licensing Program Analyst during the complaint investigation and denied the allegation |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 248
Capacity: 300
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints alleging that staff were not preventing the spread of scabies and not preventing residents from engaging in inappropriate behaviors.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not preventing the spread of scabies and staff not preventing residents from engaging in inappropriate behaviors. The department found no preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found insufficient evidence to substantiate the allegations. The facility followed proper protocols for scabies outbreak management, including notifying public health and treating residents. The behavior of a resident engaging in inappropriate behaviors was documented and managed appropriately by staff.
Report Facts
Number of residents present (census): 248
Total licensed capacity: 300
Staff interviewed: 10
Staff acknowledging scabies in Memory Care unit: 5
Residents unaware of scabies outbreak: 10
Residents diagnosed with scabies in outbreak: 4
Staff acknowledging resident digging in trash: 8
Residents recalling resident digging in trash: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Janie Acosta | Executive Director | Facility representative met during the investigation and exit interview |
| Reggie Jones | Administrator | Facility administrator at time of initial complaint visit |
Inspection Report
Complaint Investigation
Census: 247
Capacity: 300
Deficiencies: 0
Date: Mar 1, 2024
Visit Reason
The visit was an unannounced complaint investigation regarding allegations that facility staff were not dispensing medications as prescribed and not providing meals to residents during quarantine for COVID-19.
Complaint Details
The complaint alleged that facility staff failed to dispense medications and provide meals to residents during COVID-19 quarantine. The investigation found no evidence to substantiate these allegations; staff and residents denied the claims, and documentation supported proper medication administration and meal delivery.
Findings
The investigation included interviews with residents, staff, and the Executive Director, as well as review of medication administration records and menus. The allegations were denied by staff and residents, and no discrepancies were found in medication records or meal provision. The complaint was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 300
Census: 247
Staff interviewed: 7
Residents interviewed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janae Acosta | Executive Director | Met with Licensing Program Analyst and interviewed regarding allegations |
| Lizeth Villegas | Licensing Program Analyst | Conducted complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 242
Capacity: 300
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that staff did not prevent a resident from physically assaulting another resident in care.
Complaint Details
The complaint alleged that staff failed to prevent a resident from physically assaulting another resident. Interviews with the Executive Director, staff, and residents mostly denied the allegation. One resident reported a physical fight with a roommate but felt safe after a room change. The investigation found no sufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Findings
The investigation included interviews with staff, residents, and review of resident records. The Executive Director and staff denied the allegation, most residents reported feeling safe, and one resident could not remember the incident. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 300
Census: 242
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
| Sidona Cordis | Resident Care Director | Met with during the investigation and exit interview |
| Janie Acosta | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 242
Capacity: 300
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that facility staff failed to change residents' diapers, reposition bedridden residents, and provide residents with basic services.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to change resident's diaper, failure to reposition bedridden residents, and failure to provide basic services. Interviews with staff and residents, and review of logs did not support the allegations.
Findings
The investigation included interviews with staff, residents, and review of logs. All allegations were denied by staff and most residents, and no discrepancies were found in documentation. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 300
Census: 242
Staff interviewed: 9
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
| Sidona Cordis | Resident Care Director | Interviewed during the investigation regarding allegations |
| Janie Acosta | Executive Director | Participated in exit interview and acknowledged report |
Inspection Report
Complaint Investigation
Census: 244
Capacity: 300
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 12/26/2023 regarding staff not preventing resident altercations, facility malodor, insect presence, and failure to check resident blood sugar.
Complaint Details
The complaint included allegations that staff did not prevent a resident from hitting another resident, did not prevent the facility from becoming malodorous, did not keep the facility free of insects, and did not check residents' blood sugar. Interviews with the Executive Director, staff, and residents, as well as document reviews and facility tours, did not substantiate these allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents mostly denied the claims, and observations did not confirm the issues. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 300
Census: 244
Staff interviewed: 5
Residents interviewed: 10
Dates of Terminix service visits: Invoices dated 12/04/23, 12/18/23, and 12/26/23 were reviewed
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Executive Director | Interviewed regarding allegations and participated in exit interview |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 243
Capacity: 300
Deficiencies: 0
Date: Dec 14, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that a resident burned another resident with a cigarette.
Complaint Details
The complaint alleged that Resident #1 had cigarette burns caused by another resident. Interviews with staff, residents, and a witness did not confirm the allegation. Photos of possible burn marks were received but could not be verified as to when or where they occurred. The allegation was determined to be unsubstantiated.
Findings
The investigation included interviews with the Executive Director, staff, residents, and a witness, as well as review of relevant documents. The allegation was found to be unsubstantiated due to lack of preponderance of evidence to prove the incident occurred.
Report Facts
Capacity: 300
Census: 243
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Executive Director | Met during investigation and named in findings |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 246
Capacity: 300
Deficiencies: 0
Date: Nov 17, 2023
Visit Reason
The visit was an unannounced complaint investigation regarding the allegation that staff were not properly addressing scabies at the facility.
Complaint Details
The complaint alleged that staff were not properly addressing scabies at the facility. Interviews with 10 residents and 10 of 11 staff denied the allegation, while 1 staff member corroborated it. The facility had reported scabies cases to the public health department and followed treatment protocols. The allegation was deemed unsubstantiated.
Findings
The investigation included interviews with staff, residents, and a records review. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, despite one staff member corroborating the claim. The facility reported scabies cases and followed the recommended treatment plan.
Report Facts
Capacity: 300
Census: 246
Staff interviewed: 11
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sidona Cordis | Resident Care Director | Interviewed during investigation and exit interview |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 246
Capacity: 300
Deficiencies: 1
Date: Nov 17, 2023
Visit Reason
The visit was a case management visit conducted to issue a citation observed during a complaint investigation related to the facility's failure to report a scabies case to community care licensing.
Complaint Details
Complaint control # 11-AS-20231114134358. The citation was issued due to failure to report a scabies case during the complaint investigation.
Findings
The facility failed to report a scabies case to community care licensing as required by California Code of Regulations, Title 22, Division 6 and Chapter 8, resulting in a citation.
Deficiencies (1)
Failure to report scabies case to community care licensing as required by reporting requirements.
Report Facts
Capacity: 300
Census: 246
Plan of Correction Due Date: Nov 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sidona Cordis | Resident Care Director | Met during the visit and named in the exit interview |
| Janae Hammond | Licensing Program Manager | Supervisor named in the report |
| Lizeth Villegas | Licensing Program Analyst | Licensing evaluator who conducted the visit and signed the report |
Inspection Report
Annual Inspection
Census: 241
Capacity: 300
Deficiencies: 1
Date: Oct 13, 2023
Visit Reason
The visit was an unannounced annual required inspection using the CARE Inspection Tool to evaluate compliance with licensing requirements for the facility.
Findings
The facility was generally found to be in good condition with proper maintenance of resident rooms, safety equipment, and supplies. However, a deficiency was cited related to medication administration documentation where evening medications were not checked off on the MAR and no documentation was present to confirm if residents took or refused their medications.
Deficiencies (1)
Evening medication was not checked off on MAR and there was no documentation detailing if resident took or refused the prescribed medication, posing a potential health, safety or personal rights risk.
Report Facts
Deficiency Plan of Correction Due Date: Oct 27, 2023
Staff records reviewed: 10
Resident records reviewed: 10
Medication Administration Records reviewed: 10
Number of bedrooms: 278
Number of common bathrooms: 4
Number of hospice residents allowed: 30
Number of bedridden residents allowed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Executive Director | Met during inspection and named in exit interview |
| Lizeth Villegas | Licensing Program Analyst | Conducted inspection and authored report |
| Janae Hammond | Licensing Program Manager | Supervisor and named in report |
Inspection Report
Complaint Investigation
Census: 240
Capacity: 300
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2023-10-02 regarding pest control issues, food quality, and sanitation of eating utensils and dishes at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to address pest control, serving poor quality food, and use of unsanitary or hazardous eating utensils. Interviews with residents, staff, and review of documentation did not provide sufficient evidence to substantiate the allegations.
Findings
The investigation found that the facility has a pest control contract with Terminix, which visits twice monthly, and no evidence supported the allegations of poor food quality or hazardous dishes. Resident and staff interviews yielded mixed reports on pest sightings, but overall no violations were substantiated, and no immediate concerns were observed during the visit.
Report Facts
Facility capacity: 300
Census: 240
Pest control visits: 2
Residents interviewed: 10
Staff interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Administrator | Facility administrator present during investigation and exit interview |
| Sidonia Cordis | Resident Care Director | Met with Licensing Program Analyst during investigation |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 239
Capacity: 300
Deficiencies: 0
Date: Sep 16, 2023
Visit Reason
The inspection was conducted as a complaint investigation following allegations of sexual abuse and neglect resulting in unexplained bruising of a resident.
Complaint Details
The complaint alleged that a resident was sexually abused while in the facility's care and that facility staff neglected the resident resulting in unexplained bruising. The investigation included interviews with staff, residents, witnesses, and review of police, hospital, and hospice records. The allegations were unsubstantiated due to lack of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations of sexual abuse and neglect. Multiple interviews, record reviews, and observations concluded that the bruising could be related to medical conditions and other factors, and no evidence of sexual assault was found.
Report Facts
Facility capacity: 300
Census: 239
Complaint received date: Mar 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Administrator | Interviewed regarding allegations and resident care |
| Ernand Dabuet | Licensing Program Analyst | Conducted subsequent complaint visit and investigation |
| Jeremiah Randle | Licensing Program Analyst | Conducted initial complaint visit |
| Douglas Real | Special Investigator | Assigned to full investigation and conducted interviews and record reviews |
| Andrea Perez | Marketing Director | Met with Licensing Program Analyst during visit and exit interview |
Inspection Report
Complaint Investigation
Census: 239
Capacity: 300
Deficiencies: 0
Date: Aug 31, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 07/31/2023 regarding staff not ensuring timely turning of a resident and the facility being malodorous.
Complaint Details
The complaint alleged that staff were not turning a resident timely and that the facility was malodorous. Interviews with 9 staff and 10 residents denied the allegations. Documentation and observations supported that residents were repositioned every two hours and the facility was clean. The complaint was unsubstantiated.
Findings
The investigation found no substantiated evidence for the allegations. Interviews with staff and residents, review of service plans, turning logs, and housekeeping schedules showed compliance with care and cleanliness standards. The allegations were determined to be unsubstantiated.
Report Facts
Complaint Control Number: 11
Number of residents interviewed: 10
Number of staff interviewed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Executive Director | Met with Licensing Program Analyst during investigation and denied allegations |
| Lizeth Villegas | Licensing Program Analyst | Conducted complaint investigation visit and interviews |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 237
Capacity: 300
Deficiencies: 0
Date: Aug 25, 2023
Visit Reason
The inspection was conducted as a 10-day complaint investigation visit regarding an allegation that facility staff were not addressing a bed bug infestation.
Complaint Details
The complaint alleged that facility staff were not addressing bed bug infestation. The investigation included interviews, records review, and facility tour. The allegation was found unsubstantiated as evidence did not meet the preponderance of evidence standard.
Findings
Based on records reviewed, observations, and interviews, the allegation of a bed bug infestation was found to be unsubstantiated. No bed bugs were observed during the visit, and records indicated no infestation for over a year.
Report Facts
Capacity: 300
Census: 237
Pest control spray duration: 4
Scheduled deep cleaning date: Aug 31, 2023
Emergency visit date: Aug 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janie Acosta | Executive Director | Participated in the investigation and exit interview |
| Sidonia Cordis | Resident Care Director | Participated in the investigation and facility tour |
Inspection Report
Complaint Investigation
Census: 237
Capacity: 300
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation regarding an allegation that facility staff did not take residents to scheduled medical appointments.
Complaint Details
The complaint alleged that facility staff did not take residents to scheduled medical appointments. The allegation was investigated through interviews with staff and residents, and review of relevant documents. The allegation was found to be unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found insufficient evidence to support the allegation that facility staff did not take residents to scheduled medical appointments. Staff and residents denied the allegation, and documentation showed that transportation services were available and provided when requested. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 300
Census: 237
Staff interviewed: 3
Residents interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeremiah Randle | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Janie Acosta | Executive Director | Facility representative who met with the Licensing Program Analyst and provided documents |
| Reggie Jones | Administrator | Named as facility administrator in the report |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 231
Capacity: 300
Deficiencies: 0
Date: May 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation initiated due to an allegation that a resident sustained multiple injuries while in care, and additional allegations regarding staff training and vehicle maintenance.
Complaint Details
The complaint alleged that a resident sustained multiple injuries while in care. The investigation included interviews with residents, staff, and review of medical and vehicle maintenance records. The resident was injured when falling out of a wheelchair in the facility van. The allegation was substantiated. Other allegations regarding staff training and vehicle condition were unsubstantiated.
Findings
The allegation that a resident sustained multiple injuries while in care was substantiated based on interviews and record reviews. However, allegations that facility staff were not properly trained and that the facility vehicle was not in good repair were found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 300
Census: 231
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Bender | Administrator | Named in relation to staff training and facility operations during complaint investigation |
| Janie Acosta | Administrator | Met with Licensing Program Analyst during investigation |
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 230
Capacity: 300
Deficiencies: 1
Date: May 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2020-08-05 regarding allegations including resident pressure ulcers, untimely diaper changes, unlawful eviction, and medication mismanagement.
Complaint Details
The complaint investigation was triggered by allegations received on 2020-08-05 concerning resident pressure ulcers, untimely diaper changes, unlawful eviction, and medication mismanagement. The medication mismanagement allegation was substantiated, while the others were unsubstantiated.
Findings
The investigation found the allegations of pressure ulcers, untimely diaper changes, and unlawful eviction to be unsubstantiated. However, the allegation of staff mismanaging a resident's medication was substantiated due to medication being put on hold without directives, posing an immediate health and safety issue.
Deficiencies (1)
Failure to provide residents with safe, healthful and comfortable accommodations and equipment as evidenced by mismanagement of medication Quetiapine, which was put on hold without directives.
Report Facts
Capacity: 300
Census: 230
Deficiencies cited: 1
Plan of Correction Due Date: May 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martessa Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Brad Dehaan | Administrator | Facility administrator involved in interviews and findings |
| Janie Aosta | Administrator | Facility administrator met during investigation visit |
Inspection Report
Complaint Investigation
Census: 231
Capacity: 300
Deficiencies: 0
Date: Apr 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation initiated due to allegations received on 03/10/2023 regarding medication safeguarding, medication administration, elevator operation, and elevator permit status at Vista Del Mar Senior Living Facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to safeguard residents' medications, failure to give medications as prescribed, elevator malfunction, and expired elevator permit. Interviews with residents, staff, and family members, as well as record reviews, did not support the allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Medication safeguarding and administration were found to be properly managed with no missing pills. The elevator was reported slow and occasionally down for service but no residents were stuck inside. The elevator permit had expired but was in the process of renewal. Overall, the allegations were unsubstantiated.
Report Facts
Capacity: 300
Census: 231
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Administrator | Met with Licensing Program Analyst during investigation and named in report |
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 231
Capacity: 300
Deficiencies: 1
Date: Apr 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that facility staff did not safeguard residents' personal belongings, medications, and did not provide a safe environment for residents in care.
Complaint Details
The complaint investigation was substantiated for the allegation that facility staff did not safeguard residents' personal belongings, specifically a lost package signed for by front desk staff. The allegations that staff did not safeguard residents' medications and did not provide a safe environment were unsubstantiated.
Findings
The investigation substantiated the allegation that facility staff did not safeguard residents' personal belongings, citing a lost package incident. However, allegations that staff did not safeguard residents' medications and did not provide a safe environment were found to be unsubstantiated.
Deficiencies (1)
85072 Personal Rights (b) The licensee shall insure that each client is accorded the following personal rights.(6) To possess and use his/her own personal items, including his/her own toilet articles. This requirement was not met as evidenced by failure to safeguard residents' personal belongings.
Report Facts
Capacity: 300
Census: 231
Deficiency due date: Apr 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Administrator | Named in findings related to safeguarding residents' personal belongings and medications |
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 231
Capacity: 300
Deficiencies: 0
Date: Apr 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-11-07 regarding allegations of failure to feed a resident, lack of supervision, failure to clean residents' linens, and locking a resident in a room.
Complaint Details
The complaint involved four allegations: 1) Facility staff failed to feed resident; 2) Facility not supervising resident while in care; 3) Facility staff failed to clean residents' linens; 4) Facility staff locked resident in room. The investigation included interviews with staff, residents, and review of medical and care records. The allegations were found to be unsubstantiated.
Findings
The investigation found all allegations unsubstantiated based on interviews, observations, and review of supporting documentation. Staff were found to provide meals, supervision, hygiene care, and residents were not locked in rooms.
Report Facts
Capacity: 300
Census: 231
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Janie Acosta | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 228
Capacity: 300
Deficiencies: 0
Date: Apr 8, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2023-02-13 regarding food quality, dietary needs, and staff behavior at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included poor food quality, unmet special dietary needs, staff yelling at residents, and inappropriate staff communication. The investigation found no preponderance of evidence to prove these violations.
Findings
The investigation found no evidence to substantiate the allegations. Interviews, observations, and record reviews indicated that food quality and dietary needs were appropriately managed and staff did not yell at or speak inappropriately to residents.
Report Facts
Capacity: 300
Census: 228
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation |
| Sidonia Cordis | Resident of Care Services Director | Met with during investigation and exit interview |
| Janae Hammond | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 228
Capacity: 300
Deficiencies: 0
Date: Apr 8, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2023-03-27 alleging that the facility did not provide the responsible party with residents' records as requested.
Complaint Details
The complaint alleged the facility did not provide responsible party with residents records as requested. The allegation was unsubstantiated after investigation revealed the facility provided the requested records within two business days as required by Title 22 regulations.
Findings
The investigation included interviews and record reviews and found that the facility provided the requested resident's file within the required timeframe. Interviews with staff and residents did not support the allegation. The complaint was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 300
Census: 228
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janie Acosta | Executive Director | Interviewed during complaint investigation and involved in findings |
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 226
Capacity: 300
Deficiencies: 0
Date: Feb 8, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2022-09-14 regarding improper assessment of residents' needs, failure to prevent residents from pushing each other, and not providing a comfortable environment for residents.
Complaint Details
The complaint was unsubstantiated based on interviews with staff (S1-S4) and residents (R1-R23), observations, and records reviewed. Allegations included improper assessment of residents' needs, failure to prevent pushing, and inadequate environment. The facility has zero tolerance for physical abuse and staff are mandated reporters.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Staff and residents interviewed denied the allegations, stating that residents' needs are properly assessed, staff prevent pushing incidents, and a comfortable environment is provided. The complaint was deemed unsubstantiated and no deficiencies were cited.
Report Facts
Complaint Control Number: 11-AS-20220914141831
Number of staff interviewed: 4
Number of residents interviewed: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Cifuentes | Licensing Program Manager | Named in report as Licensing Program Manager |
| Janie Acosta | Executive Director | Met with Licensing Program Analyst during investigation |
| Reggie Jones | Administrator | Facility Administrator named in report |
Inspection Report
Annual Inspection
Census: 225
Capacity: 300
Deficiencies: 0
Date: Nov 4, 2022
Visit Reason
An unannounced annual required visit was conducted with a primary focus on infection control measures at Vista Del Mar Senior Living Facility.
Findings
The facility was found to be clean, well-maintained, and in good repair with proper infection control practices observed. No deficiencies were noted and no citations were issued during the inspection.
Report Facts
Non-ambulatory residents: 167
Ambulatory residents: 75
Memory Care Unit residents: 38
Bedrooms: 278
Common bathrooms: 4
Carbon Monoxide Detectors: 60
Smoke Detectors: 60
Fire Extinguishers: 12
First aid kits: 12
Resident files reviewed: 10
Resident medications reviewed: 10
Staff files reviewed: 10
PPE supply: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reggie Jones | Administrator | Named as facility administrator and noted for certification renewal in process |
| Jose Calderon | Licensing Program Analyst | Conducted the inspection and authored the report |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 225
Capacity: 300
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations received on 2021-03-01 regarding unqualified staff administering medications, scabies outbreak, ringworm outbreak, presence of roaches and bed bugs, food quality, and facility cleanliness.
Complaint Details
The complaint included allegations that unqualified staff administered medications, the facility had scabies and ringworm outbreaks, presence of roaches and bed bugs, food was not of adequate quality, and the facility was not clean. The investigation found no substantiated evidence for these allegations.
Findings
The investigation included interviews with the administrator, staff, and residents, review of records, and facility tours. All allegations were found to be unsubstantiated based on interviews, documentation, and observations, including medication administration, scabies and ringworm outbreaks, pest presence, food quality, and facility cleanliness.
Report Facts
Capacity: 300
Census: 225
Pest control visits: 2
Scabies outbreak cases: 1
Scabies outbreak suspected cases: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reggie Jones | Administrator | Met with during inspection and provided information regarding allegations |
| Brad DeHaan | Former Administrator | Interviewed regarding allegations and facility practices |
| Martessa Brown | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 183
Capacity: 300
Deficiencies: 0
Date: Apr 19, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff refused to take a resident back into care.
Complaint Details
The complaint alleged that staff refused to take a resident back into care. Interviews with staff, residents, and review of medical records showed the resident was aggressive due to dementia and was taken for medication adjustment. The facility did not refuse care but required medication adjustment. The allegation was unsubstantiated.
Findings
The investigation found that the resident with late stage dementia and aggressive behavior was taken to the hospital for medication adjustment and was returned to the facility. Staff and residents interviewed confirmed no refusal to take the resident back. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 300
Census: 183
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation |
| Reggie Jones | Administrator | Interviewed during the investigation and exit interview |
| James Bender | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 188
Capacity: 300
Deficiencies: 5
Date: Apr 18, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 2020-12-14 regarding a resident sustaining a fracture while in care, failure to seek timely medical attention, and presence of insects in the facility.
Complaint Details
The complaint investigation was substantiated. Allegations included a resident being dropped by staff causing a fracture, failure to seek timely medical attention, and presence of insects. The resident reported being dropped by staff, which was supported by medical records showing a fracture. Staff delayed sending the resident to the ER. The facility had cockroaches which were treated and eliminated.
Findings
The investigation substantiated that a resident was dropped by staff causing a shoulder fracture, the facility delayed seeking timely medical attention for the resident, and the facility had a cockroach infestation which was later eliminated. Violations were cited and a civil penalty of $500 was issued.
Deficiencies (5)
Staff dropping resident and fracturing his shoulder, posing a potential health and safety risk.
Failure to immediately call 9-1-1 after injury resulting in delayed medical attention to resident.
Facility had cockroaches, posing a potential health and safety risk.
Facility was not clean, safe, sanitary and in good repair at all times.
Administrator failed to get immediate help for resident, posing a potential health and safety risk.
Report Facts
Civil penalty amount: 500
Capacity: 300
Census: 188
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brad Dehaan | Administrator | Named in relation to allegation 3 and interviewed during investigation. |
| James Bender | Vice President | Met with during investigation and exit interview. |
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation. |
| Dennis Douglas | Investigator | Investigated allegations 1 and 2. |
| Janae Hammond | Licensing Program Manager | Oversaw licensing program and signed report. |
Inspection Report
Complaint Investigation
Capacity: 300
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
The inspection was an unannounced complaint investigation initiated due to allegations that the facility was not allowing a resident to have visitors and that a resident was being neglected while in care.
Complaint Details
The complaint involved two allegations: 1) Facility not allowing resident to have visitors, and 2) Resident being neglected while in care. The investigation was unsubstantiated due to lack of evidence supporting the allegations.
Findings
The investigation found that the allegation regarding visitor restrictions was due to the resident's power of attorney not allowing a specific visitor, and the resident expressed satisfaction with care and no desire to see that visitor. The allegation of neglect was unsubstantiated as multiple interviews indicated the resident was receiving good care and no neglect was reported.
Report Facts
Facility capacity: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Reggie Jones | Administrator | Facility administrator interviewed during investigation |
| James Bender | Administrator | Named as facility administrator in report header |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 186
Capacity: 300
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility was not following COVID protocol.
Complaint Details
Allegation: Facility is not following COVID protocol. Interviews with staff and residents indicated compliance with cleaning and mask-wearing protocols. One witness stated the facility does not supply clean masks to staff and does not pay overtime due to COVID-19. Overall, evidence did not support the allegation, resulting in an unsubstantiated finding.
Findings
The investigation included interviews with staff, residents, and review of cleaning and disinfection records. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 300
Census: 186
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation |
| Reggie Jones | Administrator | Facility administrator interviewed during investigation |
| James Bender | Administrator | Named as facility administrator in report header |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 184
Capacity: 300
Deficiencies: 2
Date: Dec 1, 2021
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to complaints alleging that a resident required a higher level of care, was left in a soaked diaper and urine saturated dressing, and had a worsening wound and pressure injury while in care.
Complaint Details
The complaint investigation was triggered by allegations that a resident required a higher level of care, was left in a soaked diaper and urine saturated dressing, and had a worsening wound and pressure injury while in care. The first two allegations were found unsubstantiated, while the third was substantiated based on interviews, record reviews, and physical evidence.
Findings
The investigation found the allegations that the resident required a higher level of care and was left in a soaked diaper and urine saturated dressing to be unsubstantiated due to lack of evidence. However, the allegation that the resident had a worsening wound and pressure injury while in care was substantiated, with findings that the facility failed to ensure proper wound care and diagnosis by a skilled professional, resulting in a Stage 4 pressure ulcer. Two deficiencies were cited related to healing wounds and observation of the resident.
Deficiencies (2)
Failure to ensure residents with stage one or two pressure injuries had the condition diagnosed by a physician or appropriately skilled professional and to receive care for the pressure injury.
Failure to regularly observe residents for changes in physical, mental, emotional, and social functioning and provide appropriate assistance when unmet needs are revealed.
Report Facts
Census: 184
Total Capacity: 300
Deficiency Count: 2
Plan of Correction Due Date: Dec 15, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation report |
| Brad Dehaan | Administrator | Facility administrator mentioned in relation to care and staffing |
| Reggie Jones | Assistant Administrator | Met with Licensing Program Analyst during inspection and exit interview |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 300
Deficiencies: 2
Date: Sep 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation initiated due to allegations that the facility had bed bugs and failed to report an unusual incident.
Complaint Details
The complaint investigation was substantiated. The facility had bed bugs affecting Resident #1, and the facility did not report the bed bug outbreak to social services as required.
Findings
The investigation substantiated that Resident #1 had bed bugs contracted from Resident #2, and the facility failed to report the bed bug outbreak to social services, posing a health and safety risk to residents.
Deficiencies (2)
The facility was not clean, safe, sanitary, and in good repair at all times, as Resident #1 was infected with bed bugs while in placement.
The licensee failed to report the bed bug outbreak to VA social services or Department of Social Services.
Report Facts
Capacity: 300
Census: 181
Deficiency count: 2
Plan of Correction Due Date: Oct 1, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| James Bender | Licensee | Facility representative interviewed during investigation |
| Brad Dehaan | Administrator | Named as facility administrator in report |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 300
Deficiencies: 0
Date: Sep 20, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff were not meeting residents' dietary needs.
Complaint Details
The complaint alleged that staff were not meeting residents' dietary needs. Interviews with staff and residents revealed mixed opinions, with one resident claiming the facility did not follow doctor's instructions and others confirming adherence to dietary plans. The resident in question has dementia and frequently changes meal preferences. The allegation was unsubstantiated.
Findings
The investigation found that while some residents and staff acknowledged issues with dietary preferences and food quality, the facility generally followed doctors' instructions. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 300
Census: 181
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
| James Bender | Licensee | Met with during the investigation and exit interview |
| Reggie Jones | Administrator | Interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 166
Capacity: 300
Deficiencies: 0
Date: Aug 19, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to multiple allegations including pressure injuries, falls, medication errors, dehydration, feeding issues, failure to notify authorized representatives of health changes, and safeguarding of personal belongings.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included multiple pressure injuries, multiple falls, medication not given as prescribed, severe dehydration, failure to ensure feeding, failure to notify authorized representative of health changes, and failure to safeguard personal belongings. Investigations included interviews with staff and residents, review of medical and facility records, and observations. No violations were substantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Medical records, interviews, and facility documentation did not confirm multiple pressure injuries, unreported falls, medication errors, dehydration due to neglect, feeding issues, failure to notify representatives, or theft of personal belongings. The allegations were deemed unsubstantiated.
Report Facts
Facility capacity: 300
Resident census: 166
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation |
| James Bender | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 166
Capacity: 300
Deficiencies: 0
Date: Aug 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation initiated due to allegations including a resident sustaining serious injury resulting in hospitalization, multiple unwitnessed falls, and multiple unexplained scab wounds.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included serious injury resulting in hospitalization, multiple unwitnessed falls, and unexplained scab wounds. Interviews with involved parties and medical record reviews did not find evidence of neglect or abuse. The resident could not be interviewed due to dementia.
Findings
The investigation found no evidence of neglect or abuse related to the allegations. Interviews and medical record reviews indicated the resident had unwitnessed falls and injuries consistent with accidental bumps and bruises, with fall prevention plans in place. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 300
Census: 166
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and report |
| James Bender | Administrator | Facility administrator met during investigation and exit interview |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 180
Capacity: 300
Deficiencies: 0
Date: Jul 29, 2021
Visit Reason
An unannounced annual required visit was conducted with a primary focus on infection control measures.
Findings
The facility was found to be clean, appropriately furnished, and in good repair with adequate infection control practices observed. No deficiencies were cited under California code of regulation title 22, division 6, chapter 8 during this visit.
Report Facts
Residents in care: 180
Facility capacity: 300
Memory Care Unit residents: 34
Non-ambulatory residents: 110
Ambulatory residents: 70
Bedrooms: 278
PPE supply: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the inspection and authored the report |
| Brad DeHaan | Administrator | Facility administrator met during the inspection |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 300
Deficiencies: 0
Date: Jul 29, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations of lack of supervision resulting in a resident being physically assaulted by another resident, and that the facility did not seek medical attention in a timely manner.
Complaint Details
The complaint alleged lack of supervision resulting in a resident being physically assaulted by another resident, and failure to seek timely medical attention. The investigation included interviews with witnesses, staff, residents, and review of video footage, hospital and physician reports, and SIR report. The allegation was found unsubstantiated.
Findings
The investigation found that although the altercation between two residents occurred, there was no evidence of injury or failure to seek timely medical attention. Both residents and staff confirmed no injuries, and hospital and physician reports did not support injury from the incident. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 300
Census: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Brad DeHaan | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 300
Deficiencies: 0
Date: Jul 26, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a resident was not provided medical care in a timely manner.
Complaint Details
The complaint alleged that a resident was not provided medical care in a timely manner. The investigation revealed that the resident had a rash treated promptly by caregivers, with family notification and physician involvement. No evidence supported the allegation, resulting in an unsubstantiated finding.
Findings
The investigation included interviews with staff, residents, and the facility doctor, as well as review of relevant records and facility conditions. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 300
Census: 178
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Brad DeHaan | Administrator | Facility administrator interviewed during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 300
Deficiencies: 0
Date: Jul 1, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including residents not receiving medications timely, inaccurate medication records, unqualified staff administering medication, staff threatening residents, illegal eviction, and failure to contact family timely after a resident's death.
Complaint Details
The complaint was unsubstantiated. Allegations included missed medications, untimely medication administration, inaccurate medication records, unqualified staff administering medication, staff threats, illegal eviction, and failure to contact family after resident death. Investigation revealed no substantiation for these claims.
Findings
The investigation found no evidence to substantiate the allegations. Medication was generally administered timely except for one incident on 07/10/2019 due to staff emergency. Staff were certified Medication Technicians. Residents and staff denied any threats. The alleged illegal eviction was due to medical necessity and proper procedures were followed. The allegation regarding failure to contact family after a resident's death was unsubstantiated due to lack of evidence and confidentiality laws.
Report Facts
Facility capacity: 300
Census: 174
Date of complaint received: Mar 3, 2020
Date of medication incident: Jul 10, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brad DeHaan | Administrator | Met during investigation and involved in discussion of allegations |
| Sidonia Cordis | Residential Care Director | Met during investigation and involved in discussion of allegations |
| Nicol Wesley | Licensing Program Analyst | Conducted the complaint investigation |
| Luis Mora | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Rebecca Orendain | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 300
Deficiencies: 0
Date: May 28, 2021
Visit Reason
The inspection was an unannounced complaint investigation initiated due to allegations that staff were not following physician's orders to place a resident in a private room and to provide showering as ordered.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations involved staff not following physician's orders regarding a resident's private room placement and showering schedule. Interviews with staff and residents confirmed adherence to doctors' orders and no issues with service.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations occurred, and therefore the allegations were unsubstantiated.
Report Facts
Capacity: 300
Census: 172
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Brad DeHaan | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 300
Deficiencies: 0
Date: May 28, 2021
Visit Reason
An unannounced complaint investigation was initiated based on a complaint received on 2021-03-23 alleging that the licensee did not bathe or groom a resident as required.
Complaint Details
The complaint alleged that a resident was not bathed or groomed as paid for, and that the resident had scabies. Interviews with residents and staff, review of cleaning schedules and medical reports, and pest control records found no evidence of scabies or failure to provide bathing and grooming services. The allegation was unsubstantiated.
Findings
The investigation included interviews with staff and residents, review of medical and cleaning records, and a facility tour. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 300
Census: 172
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brad DeHaan | Administrator | Met during investigation and exit interview |
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 168
Capacity: 300
Deficiencies: 2
Date: Jan 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 07/17/2020 regarding resident pressure injuries and pest issues at the facility.
Complaint Details
The complaint investigation was substantiated for allegations that a resident developed pressure injuries while in care and that the facility had pest problems. Other allegations related to incontinence care, staffing, basic services, personal care supplies, hot water, and hazardous items were unsubstantiated.
Findings
The investigation substantiated that a resident developed pressure injuries while in care and that the facility had pest issues including roaches and bed bugs. Other allegations such as insufficient staffing, lack of basic services, unsecured personal care supplies, lack of hot water, and hazardous items accessible to residents were found unsubstantiated.
Deficiencies (2)
Failure to provide assistance in meeting necessary medical needs, specifically related to pressure injuries worsening without immediate medical care.
Facility was not clean, safe, sanitary, and in good repair due to presence of roaches, bed bugs, and flying insects.
Report Facts
Capacity: 300
Census: 168
Deficiencies cited: 2
Plan of Correction Due Date: Jan 28, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brad Dehaan | Administrator | Facility Administrator involved in the investigation and exit interview |
| Erik Brown | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Michael Cava | Licensing Program Manager | Manager overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 203
Capacity: 300
Deficiencies: 0
Date: Nov 5, 2020
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2020-08-06 regarding the facility's alleged failure to seek timely medical attention for a resident after an unwitnessed fall.
Complaint Details
The complaint alleged that the facility did not seek timely medical attention for resident R1 after an unwitnessed fall. The investigation included interviews with staff, family members, and review of resident records. The complaint was found to be unsubstantiated.
Findings
The investigation found that the resident was transported to the hospital the same day the facility staff became aware of the resident's pain. Interviews and record reviews did not substantiate the allegation, and the complaint was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 300
Census: 203
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brad DeHaan | Administrator | Met with during investigation and exit interview |
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation |
| Peter Zertuche | Investigator | Assigned to complaint investigation |
Inspection Report
Complaint Investigation
Census: 212
Capacity: 300
Deficiencies: 1
Date: Oct 21, 2020
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 06/01/2020 alleging that the facility had insects.
Complaint Details
The complaint was substantiated based on Licensing Program Analyst's observations, interviews with staff and residents, and records review. The allegation that the facility had insects was confirmed. The investigation included interviews with the administrator, staff, residents, and pest control technician, as well as review of pest control invoices and resident records.
Findings
The investigation substantiated the allegation that the facility had insects based on interviews with staff, residents, and review of pest control records. Pest control services were provided monthly, but the administrator did not ensure the facility was free of insects, posing a potential health and safety risk.
Deficiencies (1)
The facility was not maintained free of insects, posing a potential health and safety risk to residents.
Report Facts
Capacity: 300
Census: 212
Deficiency due date: Oct 26, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brad Dehaan | Administrator | Facility administrator interviewed regarding the insect allegation and involved in the investigation |
| Martessa Brown | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Janae Hammond | Supervisor | Supervisor overseeing the complaint investigation |
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