Inspection Reports for Vista Del Mar Senior Living

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.

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.

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.

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.

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.

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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.

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.

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.

The inspection was an unannounced complaint investigation visit conducted to investigate the allegation that staff were not properly addressing pest infestation in the facility.

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.

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.

The visit was an unannounced complaint investigation regarding an allegation that facility staff did not provide adequate food service to a resident in care.

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.

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.

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.

The investigation found both allegations unsubstantiated after interviews with residents, staff, and witnesses, and review of relevant records. No deficiencies were cited.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced complaint investigation triggered by an allegation that staff did not keep the facility free of rodents.

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.

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.

The inspection visit was an unannounced complaint investigation conducted due to complaint number 11-AS-2025062515023.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident sustained an unexplained injury while in care.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

An unannounced complaint investigation visit was conducted in response to an allegation that staff did not ensure resident's catheter care was properly managed.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was conducted as an unannounced complaint investigation regarding an allegation that a resident had unknown exposure to fentanyl while in care.

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.

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.

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.

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.

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.

An unannounced complaint investigation visit was conducted to investigate an allegation that facility staff did not provide a resident with a bedroom chair.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

An unannounced complaint investigation visit was conducted regarding the allegation that staff allowed a resident to leave the facility without supervision.

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.

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.

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.

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).

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.

The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff did not respond to residents' calls for assistance.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced annual required inspection conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.

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.

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.

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.

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.

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.

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.

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.

The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff did not administer medication to a resident.

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.

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.

The visit was an unannounced complaint investigation triggered by an allegation that staff did not prevent a resident from attacking another resident.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was a Case Management visit conducted during a subsequent complaint visit to review the Plan of Correction for a prior complaint.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was conducted as an unannounced complaint investigation visit triggered by an allegation that staff neglected a resident resulting in dehydration.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced complaint investigation conducted in response to an allegation that staff did not prevent a resident from assaulting another resident.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced complaint investigation regarding an allegation that staff did not prevent a resident from physically assaulting another resident in care.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced complaint investigation conducted in response to an allegation that a resident burned another resident with a cigarette.

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.

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.

The visit was an unannounced complaint investigation regarding the allegation that staff were not properly addressing scabies at the facility.

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.

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.

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.

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.

Complaint control # 11-AS-20231114134358. The citation was issued due to failure to report a scabies case during the complaint investigation.

The visit was an unannounced annual required inspection using the CARE Inspection Tool to evaluate compliance with licensing requirements for the facility.

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.

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.

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.

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.

The inspection was conducted as a complaint investigation following allegations of sexual abuse and neglect resulting in unexplained bruising of a resident.

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.

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.

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.

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.

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.

The inspection was conducted as a 10-day complaint investigation visit regarding an allegation that facility staff were not addressing a bed bug infestation.

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.

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.

The inspection visit was conducted as a complaint investigation regarding an allegation that facility staff did not take residents to scheduled medical appointments.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

An unannounced annual required visit was conducted with a primary focus on infection control measures at Vista Del Mar Senior Living Facility.

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.

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.

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.

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.

An unannounced complaint investigation was conducted in response to an allegation that staff refused to take a resident back into care.

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.

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.

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.

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.

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.

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.

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.

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.

An unannounced complaint investigation was conducted in response to an allegation that the facility was not following COVID protocol.

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.

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.

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.

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.

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.

The inspection was an unannounced complaint investigation initiated due to allegations that the facility had bed bugs and failed to report an unusual incident.

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.

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.

An unannounced complaint investigation was conducted in response to an allegation that staff were not meeting residents' dietary needs.

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.

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.

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.

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.

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.

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.

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.

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.

An unannounced annual required visit was conducted with a primary focus on infection control measures.

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.

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.

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.

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.

An unannounced complaint investigation was conducted in response to an allegation that a resident was not provided medical care in a timely manner.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.