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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 11/12/2020
Date Signed: 11/15/2020 02:21:34 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
10/14/2020 and conducted by Evaluator Ulysses Coronel
COMPLAINT CONTROL NUMBER: 11-AS-20201014163307
FACILITY NAME:VISTA VERANDA ASSISTED LIVINGFACILITY NUMBER:
197608044
ADMINISTRATOR:MARCELLA CALVILLOFACILITY TYPE:
740
ADDRESS:3540 MARTIN LUTHER KING, JR.TELEPHONE:
(310) 638-4113
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:178CENSUS: 114DATE:
11/12/2020
UNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Nishith ModiTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff is verbally abusive to residents while in care
INVESTIGATION FINDINGS:
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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 , the facility administrator.

The investigation consisted of the following: On 10/20/2020 LPA conducted telephonic interviews with the administrator and 3 staff and reviewed food supply, physical plant, kitchen and resident bedrooms via video call. LPA requested copies of facility and staff records. On 11/12/2020 LPA conducted record reviews of facility and staff records. On 11/12/2020 LPA interviewed 10 out of 114 residents.

The investigation revealed the following: Regarding the allegation “Staff is verbally abusive to residents while in care.” On 10/20/2020 3 out of 3 staff interviewed denied being verbally abusive to residents and denied witnessing other staff being verbally abusive to residents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 11-AS-20201014163307
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: 11/12/2020
NARRATIVE
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Staff S1 stated that” I do observe staff using a firm tone of voice when they are trying to redirect residents’ behaviors. But they are not disrespectful, just firm." On 11/12/2020 10 out of 10 residents denied being verbally abused by staff and denied witnessing staff verbally abusing other residents. Resident R4 stated that “I have not seen anyone being mistreated. We have found the complaint allegation “Staff is verbally abusive to residents while in care.” 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, and a hard copy was provided via email to administrator Nishith Modi for signature.

Report continues on LIC9099-A.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/14/2020 and conducted by Evaluator Ulysses Coronel
COMPLAINT CONTROL NUMBER: 11-AS-20201014163307

FACILITY NAME:VISTA VERANDA ASSISTED LIVINGFACILITY NUMBER:
197608044
ADMINISTRATOR:MARCELLA CALVILLOFACILITY TYPE:
740
ADDRESS:3540 MARTIN LUTHER KING, JR.TELEPHONE:
(310) 638-4113
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:178CENSUS: 114DATE:
11/12/2020
UNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Nishith Modi TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
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9
Staff is not providing timely assistance to residents while in care
INVESTIGATION FINDINGS:
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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 , the facility administrator.

The investigation consisted of the following: On 10/20/2020 LPA conducted telephonic interviews with the administrator and 3 staff and reviewed food supply, physical plant, kitchen and resident bedrooms via video call. LPA requested copies of facility and staff records. On 11/12/2020 LPA conducted record reviews of facility and staff records. On 11/12/2020 LPA interviewed 10 out of 114 residents.

The investigation revealed the following: Regarding the allegation "Staff is not providing timely assistance to residents while in care ." On 10/20/2020 the administrator stated "There should be 1 caregiver in the RCFE side, 2 caregivers on the first floor Memory Care and 2 caregivers on the second floor Memory Care."
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20201014163307
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2020
Section Cited
CCR
87411(a)
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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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure...adequate services.
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The Administrator agreed to create a plan of correction and submit said plan to CCLD for reveiew by POC due date.
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This requirement was not met as evidenced by: Based on interviews and record reviews, the licensee failed to ensure that Facility personnel shall at all times be sufficient in numbers. On 10/18/2020 the licensee failed to ensure that caregivers were sufficient in numbers, which poses a potential health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20201014163307
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: 11/12/2020
NARRATIVE
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 Staff S1 stated that "On 10/18/2020, one staff from the second shift and one staff from the noc shift called off, we only had one caregiver assigned for the RCFE side and one caregiver assigned to both 1st and second floor Memory Care Units." On 11/12/2020 LPA observed that on 10/18/2020 there were 23 residents on Memory Care Unit 1 and 24 residents in Memory Care Unit 2. On 11/12/2020 resident R5 stated that "There is not enough staff for the number of residents here, they need more help." Based on LPA’s observations, interviews and record reviews, the preponderance of evidence standard has been met therefore the above allegation is found to be substantiated. California Code of Regulations, Tittle 22 are being cited. Please see LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed with the Administrator.

A copy of this report and appeal rights were discussed and emailed to administrator Nishith Modi for signature.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5