197608044-9-10-2020-11-AS-JHAD-BTVUVJ-20200928155513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 09/03/2020
Date Signed: 09/10/2020 04:57:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Ulysses Coronel

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200819123513

FACILITY NAME:	VISTA VERANDA ASSISTED LIVING		FACILITY NUMBER:	197608044
ADMINISTRATOR:	MARCELLA CALVILLO		FACILITY TYPE:	740
ADDRESS:	3540 MARTIN LUTHER KING, JR.		TELEPHONE:	(310) 638-4113
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY:	178	CENSUS: 133	DATE:	09/03/2020
		UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Nishith Modi		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Electrical plugs in residents room are in disrepair
Staff did not safeguard residents personal belongings

INVESTIGATION FINDINGS:

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This is an ammendment of the investigation report dated 09/03/2020, amended copy provided to Licensee.

Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Nishith Modi the person in charge.

The investigation consisted of the following:
On 09/01/2020 LPA conducted record reviews of the documents submitted by the facility on 08/26/2020. On 08/24/2020 LPA Coronel conducted telephone interviews with the Nishith Modi, 10 out of 133 of residents and 4 staff. A Facetime video call which consisted of a review of physical plant, medication room and resident R1’s bedroom was conducted. The LPA also requested copies of the Personnel Report (LIC500) and Roster of Facility Residents (LIC9020) and the Facility Sketch.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200819123513

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA VERANDA ASSISTED LIVING	FACILITY NUMBER: 197608044
	VISIT DATE: 09/03/2020

NARRATIVE

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The investigation revealed the following:

On 08/24/2020 10 out of 133 of residents interviewed did not have any concerns regarding the buildings condition, resident R8 stated that "No, it's not falling apart, it's nice and clean." 4 out of 4 staff interviewed did not have any concerns about the buildings condition, staff S1 stated that “"Everything is in okay condition, everything is okay." Staff S2 stated “Sometimes it takes a longer time for technicians to come, especially during this pandemic." Administrator Modi stated that “A service technician was scheduled to fix the said electrical outlet today, the electrical outlet receptacle in R1's room has tripped the technician just went to the electrical panel board and reset the circuit breaker and the electrical outlet is working now." During the virtual tour of the facility LPA observed that the electrical plug in R1’s bedroom was fixed the Administrator tested the electrical receptacle by plugging in an electric fan which turned on. Regarding the allegation: “Electrical plugs in residents’ room are in disrepair." We have found the complaint allegation unsubstantiated, although the allegation may have happened or is valid; there is not a preponderance of the evidence to prove that the alleged violation occurred.

On 08/24/2020 R1 stated that “If the electrical outlets were working extension cords would not have been in used which caused me to trip on them causing the TV to fall and break.” S1 stated that “When I was cleaning R1’s room the TV almost fell but I was able to catch it and put it back.” Administrator Modi stated that “We do not have maintenance staff, if something needs to be fixed, we call outside contractors to service the facility.” Staff S2 stated “Sometimes it takes a longer time for technicians to come, especially during this pandemic”. Regarding the allegations “Staff did not safeguard residents’ personal belongings.” We have found the complaint allegations unsubstantiated, although the allegation may have happened or is valid; there is not a preponderance of the evidence to prove that the alleged violation occurred.

A telephonic exit interview was conducted with Nishith Modi, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2020

LIC9099 (FAS) - (06/04)

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