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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 05/24/2021
Date Signed: 06/01/2021 08:16:41 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
197608044
ADMINISTRATOR:NISHITH MODIFACILITY TYPE:
740
ADDRESS:3540 MARTIN LUTHER KING, JR.TELEPHONE:
(310) 638-4113
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:178CENSUS: 115DATE:
05/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Nishith ModiTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a Case Management – Deficiencies visit to cite deficiencies observed during investigation of complaints with complaint numbers 11-AS-20210129145650 and 11-AS-20210428110740. Today’s Case Management - Deficiencies visit was conducted with Nishith Modi, the Administrator.

On 02/08/2021 LPA reviewed R1’s resident records did not observe any indication of R1’s Assessments, Reassessments or Needs and Services Plan, per Physicians Report dated 02/27/2019 R1 is diagnosed with Alzheimer’s Dementia, on 01/02/2021 R1 tested positive for COVID-19, on 01/03/2021 R1 was observed weak and unable to eat by S4 and again on 01/28/2021 R1 was observed weak and unable to eat by S1 and S5 and was sent to hospital per R1’s doctors order.

On 02/05/2021 LPA interviewed W1 who stated “I did not receive a call from Vista Veranda regarding R1’s prior condition or of R1’s hospitalization last week. I found out about it after receiving a call from the hospital." On 02/08/2021 LPA reviewed regional office records and observed R1’s incident dated 01/03/2021 was not reported to CCL, LPA also observed that the incident report submitted by the facility during the investigation was incomplete.

On 05/03/2021 administrator stated "We do not have an activities person, S10 resigned on April 15th and is now a caregiver staff, we are still hiring right now." During todays visit administrator stated "We are still in the process of hiring".



Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, please see LIC809-D.

A exit interview was conducted with Nishith Modi and a hard copy and licensee rights was provided to Nishith Modi.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2021
Section Cited

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87705(c)(6) Care of Persons with Dementia Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.
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This Requirement was not met as evidenced by: Based on record reviews and interviews conducted: the licensee failed to ensure that Appraisals are conducted on an ongoing basis for R1 which poses a potential health and safety risk to clients in care.
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Note: This Title 22 Regulation was cited on 02/19/2021 and is subject to civil penalty assessment.
Type B
05/31/2021
Section Cited

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87211(a)(1)(D) Reporting Requirements Each licensee shall furnish to the licensing agency..., the following: A written report shall be submitted to the licensing agency and to the person responsible...of any of the events ... case. Any incident which threatens the welfare, safety or health of any ...resident.
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This requirement was not met as evidenced by: Based on record reviews and interviews conducted the Licensee failed to ensure that written reports were submitted to the licensing agency and R1's responsible person which poses a potential risk to the health and safety of residents in care.
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Note: This Title 22 Regulation was cited on 02/19/2021 and is subject to civil penalty assessment.
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: 05/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2021
Section Cited

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87219(f)Planned Activities. In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities,... abilities. The ...responsible employee shall... be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers.
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This requirement was not met as evidenced by, based on LPA observation and interviews, the licensee failed to ensure that a full time employee organizes, conducts and evaluate planned activities. On 05/03/2021 the facility did not have an Activities director, 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: 05/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3