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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 01/13/2021
Date Signed: 01/26/2021 09:53:27 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: 111DATE:
01/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Nishith ModiTIME COMPLETED:
06:00 PM
NARRATIVE
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On 01/13/2021,administrator Nishith Modi failed to protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that facility Administrator Nishith Modi failed to wear face coverings while providing supervision to clients in care*, in violation of official government orders requiring the wearing of face coverings while working under specified conditions.

CDPH order released on June 18, 2020 – (updated on June 29 to exempt children under two years old)
https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/COVID-19/Guidance-for-Face-Coverings_06-18-2020.pdf
Mandated wearing of face masks while engaged in work when:
• interacting with any member of the public
• working in any space visited by members of the public even if member of the public not present
• working in or walking through common areas, including hallways, stairways, and elevators
• working in any room or enclosed area where other people (except for members of the person’s own household or residence) are present when unable to socially distance
• driving or operating … private car service … when passengers are present (transporting clients)
• while outdoors in public spaces when maintaining a physical distance of 6 feet from persons who are not members of the same household or residence is not feasible.
• working in any space where food is prepared or packaged for sale or distribution to others.

On 12/18/2020, 12/26/2020 and 01/02/2021 administrator Nishith Modi failed to submit reports on a total of 11 residents and 2 staff testing positive for COVID-19.

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

DATE: 01/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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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: 01/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2021
Section Cited

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87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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Based on LPA observation and interviews conducted, the administrator was observed not wearing a mask while at the facility and not implementing infection control as ordered by the Department of Public Health, which poses a potential risk to the health and safety of residents in care.
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Type B
01/18/2021
Section Cited

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87211 Reporting Requirements(a) Each licensee shall furnish ...reports as the Department may require,...following:(2) Occurrences, such as epidemic outbreaks, ... shall be reported within 24 hours either by telephone or facsimile...when appropriate.
This requirement was not met as evidenced by:
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Based on record reviews and interviews conducted the liensee fail reports are submitted to the licensing agency regarding epidemic outbreaks within 24 hours, Nishith Modi failed to report residents and staffs tesing positive which poses a potential risk to the health and safety of residents 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: 01/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2021
LIC809 (FAS) - (06/04)
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