197608044-6-2-2021-11-AS-JHAD-C3MUUH-20210603155331

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 05/24/2021
Date Signed: 06/02/2021 11:00:22 AM

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
01/29/2021 and conducted by Evaluator Ulysses Coronel

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210129145650

FACILITY NAME:	VISTA VERANDA ASSISTED LIVING		FACILITY NUMBER:	197608044
ADMINISTRATOR:	NISHITH MODI		FACILITY TYPE:	740
ADDRESS:	3540 MARTIN LUTHER KING, JR.		TELEPHONE:	(310) 638-4113
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY:	178	CENSUS: 96	DATE:	05/24/2021
		UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Nishith MOdi		TIME COMPLETED:	10:04 AM

ALLEGATION(S):

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Licensee did not meet the needs of the resident, resulting in dehydration.
Resident's oral care needs are not being met.
Resident is sleeping on the bedroom floor on a mattress.

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 Nishith Modi the administrator.

The investigation consisted of the following: On 02/01/2021 Licensing Program Manager (LPM) Janae Hammond and LPA Coronel interviewed caregiver supervisor and 1 caregiver staff. On 02/02/2021 LPM Hammond and LPA Coronel interviewed the administrator and 4 staff and requested resident and staff records. On 02/04/2021 LPA Coronel interviewed 10 out of 105 residents. On 02/04/2021 LPA interviewed witness W1. On 02/05/2021 LPA interviewed witnesses W2 and W3. On 04/14/2021 LPA reviewed R1’s medical Records.

Substantiated

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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 7

Control Number 11-AS-20210129145650

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: 05/24/2021

NARRATIVE

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The investigation revealed the following:
Regarding the allegation” Licensee did not meet the needs of the resident, resulting in dehydration.” On 02/02/2021 S2 stated “We give R1 water every 30 minutes, but R1 can't open their mouth." S5 stated “On 01/05/2021 R1 started having generalized weakness and started losing sense of taste and smell that's why R1 suddenly stopped eating then R1 just laid down, the next day the same, then the 3rd day we put the food in R1's mouth but the food just stay in R1’s mouth and does not swallow.” On 02/08/2021 LPA reviewed R1’s records and observed that per Physician’s Report dated 09/27/2019 that R1 was diagnosed with Alzheimer’s Dementia. Per medical record R1 tested positive for COVID-19 on 01/02/2021. Per incident report R1 was observed weak and unable to eat by staff S4 on 01/03/2021. Per incident report R1 was observed weak and unable to eat by staffs S1 and S5 and was sent to hospital on 01/28/2021. On 04/14/2021 LPA reviewed R1’s medical records and observed that some of R1’s diagnoses were Dehydration, Hypernatremia (most often occurs in people who don't drink enough water www.mayoclinic.org), Acute Cystisis (Urinary Tract Infection www.webmd.com) and Sepsis (the body’s extreme response to an infection www.cdc.gov). Regarding the allegation” Licensee did not meet the needs of the resident, resulting in dehydration.” Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Regarding the allegation “Resident's oral care needs are not being met.”
On 02/02/2021 S2 stated “When R1 got sick, R1 became very aggressive, R1 would not let us help brush their teeth." On 02/05/2021 witness W2 stated that “Prior to R1’s stay at the facility, R1 already needed assistance with bathing and brushing of teeth.” On 02/08/2021 LPA reviewed R1’s records and observed that per Physician’s Report dated 09/27/2019 that R1 was diagnosed with Alzheimer’s Dementia and did not have a capacity to dress/groom self. Per medical record R1 tested positive for COVID-19 on 01/02/2021. Per incident report R1 was observed weak and unable to eat by staff S4 on 01/03/2021. Per incident report R1 was observed weak and unable to eat by staffs S1 and S5 and was sent to hospital on 01/28/2021. Per hospital admission records R1’s general appearance appeared neglected with noted poor oral care. Regarding the allegation “Resident's oral care needs are not being met.” Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 11-AS-20210129145650

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: 05/24/2021

NARRATIVE

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Regarding the allegation “Resident is sleeping on the bedroom floor on a mattress.”
On 02/01/2021 S1 stated “When R1 gets weak, R1 tries to fall down. I told the caregivers to put another mattress right here on the floor so when R1 turns around, R1 is going to fall but R1's going to fall on the mattress and not on the floor." On 02/01/2021 S2 stated that “Yes, R1 sleeps on the mattress, and the mattress is on the floor." On 02/02/2021 S5 stated “R1 gets aggressive when we tell R1 to go back up to R1’s bed." On 02/08/2021 LPA reviewed R1’s records and observed that per Physician’s Report dated 09/27/2019 that R1 was diagnosed with Alzheimer’s Dementia and did not have a capacity to dress/groom self. Per medical record R1 tested positive for COVID-19 on 01/02/2021. Per incident report R1 was observed weak and unable to eat by staff S4 on 01/03/2021. Per incident report R1 was observed weak and unable to eat by staffs S1 and S5 and was sent to hospital on 01/28/2021. Regarding the allegation “Resident is sleeping on the bedroom floor on a mattress.” Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted a copy of this report and appeal rights were 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: 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

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 11-AS-20210129145650

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: 05/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/25/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes... When ...deterioration of mental ability or a physical health condition are observed, the licensee shall ensure... changes are documented and brought to the attention of the resident's physician...any.	1 2 3 4 5 6 7	The administrator will review Title 22 Regulation 87466 Observation of the Resident and create a plan of correction to ensure that that residents are regularly observed for changes and appropriate assistance is provided. Plan of correction is due by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on observations, interviews and record reviews: the licensee failed to ensure that residents are regularly observed for changes and appropriate assistance is provided, R1 was not provided with timely assistance which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 05/31/2021 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465(a)(1) Incidental Medical and Dental Care. A plan for ...dental care shall be developed by each facility. The plan shall encourage routine ...dental care and provide for assistance in obtaining such care, ...shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.	1 2 3 4 5 6 7	The administrator will review Title 22 Regulation 87465(a)(1) Incidental Medical and Dental Care and create a plan of correction to encourage routine dental care. Plan of correction is due by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on LPAs observations, interviews and the record reviews the licensee failed to ensure that dental care appropriate to the conditions and needs of residents were arranged, R1’s oral care needs were not met which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 11-AS-20210129145650

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: 05/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/31/2021 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The administrator will review Title 22 Regulation 87468.1(a)(2) Personal Rights of Residents in All Facilities and create a care of correction to ensure that residents who are fall risks are accorded safe, healthful and comfortable accommodations. Plan of correction is due by POC due date.
	8 9 10 11 12 13 14	Based on LPAs observations, interviews and the record reviews the licensee failed to ensure that residents are accorded safe, healthful and comfortable accommodations, R1’s was sleeping on a mattress on the bedroom floor which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 5 of 7

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
01/29/2021 and conducted by Evaluator Ulysses Coronel

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210129145650

FACILITY NAME:	VISTA VERANDA ASSISTED LIVING		FACILITY NUMBER:	197608044
ADMINISTRATOR:	NISHITH MODI		FACILITY TYPE:	740
ADDRESS:	3540 MARTIN LUTHER KING, JR.		TELEPHONE:	(310) 638-4113
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY:	178	CENSUS:	DATE:	05/24/2021
		UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:			TIME COMPLETED:	10:04 AM

ALLEGATION(S):

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Resident developed fungal lesions while in care.

INVESTIGATION FINDINGS:

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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: 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.

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 11-AS-20210129145650

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: 05/24/2021

NARRATIVE

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Regarding the allegation “Resident developed fungal lesions while in care.”
On 02/18/2021 LPA interviewed witness W3 who stated that “R1 has skin growths on his chest and abdomen areas these are not fungal in nature.” On 04/14/2021 LPA reviewed R1’s medical records and observed that on 01/28/2021 the hospital conducted a physical examination of R1 and noted that “R1’s skin had no rash, no pale appearance and no yellowing.” Regarding the allegation “Resident developed fungal lesions while in care.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted a copy of this report was provided to Nishith Modi.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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