Complaint·July 1, 2025

The investigation revealed the following: Allegation #1- Staff did not prevent resident from engaging in inappropriate behaviors. The details of the complaint alleged that the resident (R1) has a roommate that is sundowning and is up during the night, and R1 has caught the roommate messing with their oxygen tank. It was reported that the resident feels unsafe with their current roommate and would like to change rooms. On 7/1/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not prevent resident from engaging in inappropriate behaviors. All staff (S1-S4) interviewed stated that they had no knowledge that R1s roommate had allegedly interfered with their oxygen tank. They stated that no one told them about this issue and now that they know they will address the issue and take appropriate action. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied any knowledge of ongoing issues with resident’s engaging in inappropriate behaviors. The majority of the resident’s stated that they either do not have a roommate or that they do not have any such issues with their current roommate and/or other resident’s. The Department reviewed the Vista Del Mar Senior Living Work Order (Dated: 06/28/2025) and Facility Notes (Dated: 07/01/2025) and observed that a work order was created on 06/28/2025 to move the resident (R1) to another room in the facility. The department also observed that management was made aware of the issue between the two roommates and started the process of taking appropriate actions to resolve the concern. S1 stated that R1 was given an option to switch sides within the room to help resolve the disagreement but R1 declined the offer and chose to stay on their side of the room. Subsequently, the facility decided to move R1 and created a work order to do so on 06/28/2025. R1 is scheduled to be transferred to a new room within a week or so. Once the room has been prepped, the team will assist R1 with their move to their new location in the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not prevent resident from engaging in inappropriate behaviors. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Report Continued On LIC9099-C Allegation #2- Staff are not providing a comfortable environment for resident. The details of the complaint alleged that the resident (R1) has a roommate that is causing the resident to live in an uncomfortable environment, but the facility has not moved or changed the resident to a new room. It was reported that the roommate and their family members turn off the air condition in the bedroom when it is hot, causing the resident (R1) to feel uncomfortable. On 7/1/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff are not providing a comfortable environment for resident. All staff (S1-S4) interviewed stated that when they learned of the issue with the roommates, they took appropriate action to resolve the issue. They stated that they had a discussion with both resident’s and concluded that they would relocate R1 to another room in the facility. Staff stated that they are in the process of making that happen and it should not take more than a week to find a room and prepare it for R1 to move in. They further state that R1 will be assisted with the move by a team within the facility. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that they were comfortable with the environment within the facility and were satisfied with the care and supervision provided by the staff. The majority of the resident’s stated that they are provided a comfortable environment to live in by the facility. The Department reviewed the Vista Del Mar Senior Living Work Order (Dated: 06/28/2025) and Facility Notes (Dated: 07/01/2025) and observed that a work order was created on 06/28/2025 to move the resident (R1) to another room in the facility. The department also observed that management was made aware of the issue between the two roommates and started the process of taking appropriate actions to resolve the concern. R1 is scheduled to be transferred to a new room within a week or so. Once the room has been prepped, the team will assist R1 with their move to their new location in the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not providing a comfortable environment for resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No deficiencies were cited. An exit interview was conducted with Suzette Johnson, Executive Director, and a hard copy of this Complaint Investigation Report was provided.