Vista Del Mar Senior Living

Facility personnel sufficiency and competence

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:Based on interviews, observations, and records review, the licensee failed to ensure sufficient staffing to meet the needs of 35 residents during overnight hours. Records review confirmed that three staff were assigned to provide care during the overnight shift. Incident reports and progress notes document a pattern of residents found with injuries during morning hours, with no documentation identifying when or how the incidents occurred. This posed a potential health and safety risk to persons in care.

Facility personnel sufficiency and competence

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:Based on interviews, observations, and records review, the licensee failed to ensure sufficient staffing to meet residents needs during overnight hours, resulting in an unwitnessed fall and a pattern of unwitnessed falls where staff were unaware of when or how incidents occurred, posing an potential health and safety risk to persons in care.

Maintain separate complete record for each resident

87506 Resident RecordsThe licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidence by: based observation, records review, and interview LPA observed that MAR for R1 was not properly documented from 12/2025- 02/09/26. Medications were provided but MAR is missing several signatures which poses a potential health and safety risk to residents in care.

Maintenance and Operation…facility shall be clean…sanitary…at all times…for the safety…of residents...(f) All waste shall be located…and disposed of in a manner that will not…provide a breeding place or food source for insects or rodents. This requirement was not met as evidence by: Based on observations and record review, the licensee did not maintain a clean and sanitary environment. On 11/05/2025, LPA observed and photographed live and dead cockroaches in one resident room.This poses a potential health and safety risk to residents in care.

Obtain required California clearance or exemption

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Staff #7 is not associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on [(observation) (interview) the licensee did not comply with the section cited above as water temperatures in bedrooms 119, 135, 137, 217, and ML22 were observed to not be within range of 105 F -120 F. which poses an immediate health, safety or personal rights risk to persons in care.

Personal Accommodations and Services (3) Equipment and supplies necessary for personal care...the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets...The quantity shall be sufficient to permit...prohibited. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by R1's bed not having fitted bed sheets which poses a potential health and personal rights risk to persons in care.

Maintain records of centrally stored medication dosages

87465 Incidental Medical...care(a) A plan for incidental medical...care shall be developed by each facility. The plan...provide for assistance in obtaining such care...: (6) When requested by...a record of dosages of medications shall be maintained by the facility. This requirement has not been met as evidenced by: R1's medication admission record (MAR) in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.

Regular observation and documentation of resident changes

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. Based on interview and record reviews, the licensee failed to provide R1 with more assistance and supervision following discharge from the hospital on 04/19/24 due to being a high fall risk. R1 continued to experience multiple falls that resulted in a fracture of C5 and C6 vertebrae on 04/22/24, which poses an immediate health and safety risk to persons in care.

Safe, healthful, comfortable accommodations

Personal Rights of Residents in All FacilitiesResidents in all residential care facilities for the elderly shall have all of the following personal rights:To be accorded safe, healthful and comfortable accommodations... this requirement was not met as R1 whohas a dementia diagnosis was able to leave the facility unassisted which poses/posed a potential health, safety or personal rights risk to persons in care.

Reporting Requirements.Each licensee shall furnish to the licensing agency such reports as the Department may require...a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...(B) Any serious injury ... occurring while the resident is under facility supervision. Based on records and interviews, the facility failed to submit a written report to ccld for R1's fall within (7) days. This violation poses a potential health, safety, or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation(a) The facility shall be...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This has not been met as evidenced by: Based on CCLD's observations, the licensee has failed to ensure the facility has been maintained in good repair which poses a potential risk to residents in care.

Freedom to leave and not be locked in

Personal Rights of Residents in All FacilitiesResidents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night... Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The facility staff is following the instructions of a POA over healthcare regarding R1 right to leave the facility with visitors on outings. This poses/posed a potential health, safety or personal rights risk to persons in care.

No stage 3 or 4 pressure injuries

87615(a)(1)Persons who require health services for or have a health condition including, but not limited to...Stage 3 and 4 pressure injuries.This requirement is not met as evidenced by: Based on records review and interviews conducted the facility retained resident 1 despite being informed by the home health agency that the resident had pressure injury. This poses a health & Safety risk to residents in care.

Maintain facility in clean, safe, sanitary condition

87303(a) Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair always… Based on records reviewed and interviews conducted, the licensee failed to control roaches inside the facility for residents in care. This poses a Safety risk to residents in care.

No stage 3 or 4 pressure injuries

Prohibited Health Conditions (a) Persons who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure sores (dermal ulcers). This requirement is not met as evidenced by: Facility retained Resident #1 with a Stage IV pressure injury on its coccyx (a prohibited health condition) until the resident passed away on 09/03/21. This requirement was not met as evidenced by Based on records reviewed and interviews conducted the licensee failed to care for resident with stage 3 and 4 pressure sores. This poses a Safety risk to residents in care.

87612(a)(7) Restricted Health Conditions (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (7) Incontinence of bowel and/or bladder as specified in Section 87625. This requirement was not met as evidenced by Based on records reviewed and interviews conducted the licensee failed to provide an incontinence care log to support dates and times incontinent care has been provided to R1. LPA found R1 was diagnosed with a stage 3 pressure ulcer on the coccyx on 8/23/21. This poses a Safety risk to residents in care.

Report specified resident events within seven days

87211 Reporting requirementEach licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any, and....

Maintain records of centrally stored medication dosages

Based on observation and record review, the licensee did not comply with the section cited above as evening medication was not checked off on MAR and there was no documentation detailing if resident took or refused the prescribed medication which poses/posed a potential health, safety or personal rights risk to persons in care.

87468.1Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2)( To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement was not met as evidence by: LPA reviewed R1 medication Mars and on 6/24/2020 and 6/25/2020 Medication Mars Quetiapine was on holdThis posses an immediate health and safety issue.

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 Based on records reviewed and interviews conducted the licensee failed to ensure the safeguard of residents personal belongings. This poses a Safety risk to residents in care.

Maintain facility in clean, safe, sanitary condition

87303(a) 873039a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidence by: Based on observations and interviews Facility had roaches, which poses a potential health and safety risk for the persons in care.

87405(h)(5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified in the residents' Pre-Admission Appraisals, specified in Section 87457, Pre-admission Appraisal, and Reappraisal, as specified in Section 87463. This was not met as evidence by: Based on observations and interviews Administrator failed to get immediate help for R#1. Which poses a potential health and safety risk for persons in care.

Protection from punishment and intimidation

87468.1 (a)(3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This was not met as evidenced by Based on observations and interviews Staff dropping R1 and fracturing his shoulder. Which poses a potential health and safety risk to persons in care.

Call 9-1-1 for imminent health threats

87465(g) -The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).this was not met as evdenced by: Based on observations and interviews staff did not call or take R1 to the ER in a timely manner. Which poses a potential health and safety risk for persons in care

87631 Healing Wounds (3) Residents with a stage one or two pressure injury must have the condition diagnosed by a physician or an appropriately skilled professional. (A) The resident shall receive care for the pressure injury from a physician or an appropriately skilled professional.This requirement was not met as evidenced by: Based on LPA observations, interviews conducted and record reviews, the Licensee failed to ensure to address R1's diagnosed by skilled professional for the Stage 1&2 wounds. No wound care plan in place. This violation poses an immediate health and safety risk to residents in care.

Regular observation and documentation of resident changes

87466 Observation of the ResidentState regulations require the licensee to ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.This requirement was not met as evidenced by: Based on LPA observations, interviews conducted, and record reviews, the Licensee was aware of R1's wounds condition and incorrectly diagnosed the wound condition. This violation poses a potential health and safety risk to residents in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being ofresidents, employees and visitors. Thisrequirement was not met as evidenced by Based on records reviewed and interviews conducted the licensee failed to ensure Residents #1 was afforded a safe and comfortable accommodations. R1 was infected with bed bugs while in placement at facility. This poses a health & Safety risk to residents in care.

87211 Reporting Requirements (a) Eachlicensee shall furnish to the licensing agencysuch reports...(2) Occurrences, such asepidemic outbreaks... This requirement was not met as evidenced by: Based on records reviewed and interviewsconducted the licensee failed to report the bed bug outbreak to VA social services orDepartment of Social Services. This poses ahealth & Safety risk to residents in care.