<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 08/11/2021
Date Signed: 08/11/2021 04:57:26 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/23/2019 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20190923172523
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: 85DATE:
08/11/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Faciltiy AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was left in soiled diaper for extended period of time.
Facility failed to ensure resident was wearing clean clothing.
Resident's belongings were not safeguarded.
Resident's bathing needs are not being met.
Resident was not provided a bedroom for a period of time
Facility withheld food from resident.
Facility served spoiled food to resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced visit to further investigate the above allegations. LPA met with the Facility Administrator and discussed the purpose of today's visit.

The investigation for the above allegations was conducted by LPA Juan Pablo Miramontes. LPA Miramontes conducted visits on the following dates: 09/26/2019, 10/25/2019 and 11/22/2019.

During today's visit, LPA Irra interviewed the Facility Administrator and Staff #1 (S-1) through Staff #4 (S-4). LPA also interviewed Resident #2 (R-2) through Resident #8 (R-8). LPA reviewed the Resident file for Resident # 1 (R-1) and obtained relevant documentation. R-1 is not longer residing at this location.

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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 8
Control Number 28-AS-20190923172523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044
VISIT DATE: 08/11/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Resident was left in soiled diaper for extended period of time. During today's investigation, LPA Irra interviewed the Facility Administrator and Staff #1 (S-1) through Staff #4 (S-4). LPA also interviewed Resident #2 (R-2) through Resident #8 (R-8). R-1 is not longer residing at this location. Staff interviews revealed that staff are provided a list of Residents to assist during their shift. Per Staff interviews, the list is also utilized as log for incontinence care. Per Staff interviews, staff conduct rounds every 2 hours and as needed for incontinence care. Per Staff interviews, staff have not observed nor have received any complaints in regards to Residents being left soiled for an extended time period. Resident interviews revealed that staff conduct rounds to their rooms every 2 hours and as needed. Resident interviews revealed that staff do not leave residents in soiled diapers for an extended period of time. Per LPA Miramontes' Investigation, the "Investigation revealed the following: Complaint Report alleged that resident was left in soiled diaper entire day of 09/15/2019. Interview with family member who stated that family had taken R1 out of the facility on 09/15/2019 and went to family home and bathed and dressed R1 and returned resident to facility at approximately 12 noon. Thus resident could not have be left in soiled diaper for the extended period of time as alleged. Physician's Report does not indicate that R1 needed or required adult diapers. Physician's Report dated 09/12/19 indicates that R1 is able follow a 2 hour and as needed routine to assist Resident with incontinent care (change diapers)". Staff and Resident interviews do not corroborate this allegation.

Allegation: Facility failed to ensure resident was wearing clean clothing. During today's investigation, LPA Irra interviewed the Facility Administrator and Staff #1 (S-1) through Staff #4 (S-4). LPA also interviewed Resident #2 (R-2) through Resident #8 (R-8). R-1 is not longer residing at this location. Staff interviews revealed that staff are provided a list of Residents to assist during their shift. Per Staff interviews, the list is also utilized as log for dressing and laundry services. Per Staff interviews, Staff assist Residents with changing their clothes daily. Per Staff interviews, staff also ensure that the Residents wear clean clothing and will assist Residents changing their clothes again if needed/requested. Per Staff interviews, staff have not observed nor have received any complaints in regards to Residents not wearing clean clothing. Resident interviews revealed that staff assist them with dressing them with clean clothing every day. Resident interviews revealed that staff also assist them if they need to be changed/dressed again throughout the day. Interviewed Residents did not have any concerns with staff assisting them with dressing/changing. Staff and Resident interviews do not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 28-AS-20190923172523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044
VISIT DATE: 08/11/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Resident's belongings were not safeguarded.
During today's investigation, LPA Irra interviewed the Facility Administrator and Staff #1 (S-1) through Staff #4 (S-4). LPA also interviewed Resident #2 (R-2) through Resident #8 (R-8). R-1 is not longer residing at this location. Per Staff interviews, staff have not observed nor have received any complaints in regards to Residents belongings not being safeguarded. Resident interviews revealed that they (residents) do not have any concerns in regards to their belongings being safeguarded. Interviewed Residents indicated that their belongings have not been taken nor misplaced. Per LPA Miramontes' Investigation, "during interview family member who assisted resident #1 with the admittance process to the facility admitted that resident #1 arrived to the facility without any personal belongings, until other family member brought items of clothing and diapers. Family member interviewed indicated that in the trans course of room re-assignment supplies and clothing for resident #1 were misplaced, but then they were found. Facility staff interviewed indicated that family did not bring any supplies and facility supplied adult diapers for resident #1 to use". Staff and Resident interviews do not corroborate this allegation.

Allegation: Resident's bathing needs are not being met. During today's investigation, LPA Irra interviewed the Facility Administrator and Staff #1 (S-1) through Staff #4 (S-4). LPA also interviewed Resident #2 (R-2) through Resident #8 (R-8). R-1 is not longer residing at this location. Staff interviews revealed that staff are provided a list of Residents to assist during their shift. Per Staff interviews, the list is also utilized as log for bathing. Per Staff interviews, Residents have bathing scheduled a couple of days per week. Per Staff interviews, staff have not observed nor have received any complaints in regards to Residents not having their bathing needs met. Resident interviews revealed that staff assist them with their bathing needs. Interviewed Residents indicated they do not have any concerns with the bathing services provided by staff. Staff and Resident interviews do not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 28-AS-20190923172523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044
VISIT DATE: 08/11/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Resident was not provided a bedroom for a period of time.
During today's investigation, LPA Irra interviewed the Facility Administrator and Staff #1 (S-1) through Staff #4 (S-4). LPA also interviewed Resident #2 (R-2) through Resident #8 (R-8). R-1 is not longer residing at this location. Staff interviews revealed that the Facility Administrator is responsible in handling bedroom assignments including bedroom assignments upon admission. Resident interviews revealed that they have not requested a change of bedroom. Resident interviews revealed that they are happy with their current bedroom setting. Per LPA Miramontes' investigation, "Upon return of resident from hospital facility staff had to make other arrangements and reassign resident with a new bedroom. Administrator and staff interviewed stated that the room assignment was no more than 15 or 20 minutes in which staff had to figure which rooms and beds were vacant and which of the available rooms had compatible residents for roommates. A time frame of how long resident was without a room was not established by family member during interview". Staff and Resident interviews do not corroborate this allegation.

Allegation: Facility withheld food from resident.
During today's investigation, LPA Irra interviewed the Facility Administrator and Staff #1 (S-1) through Staff #4 (S-4). LPA also interviewed Resident #2 (R-2) through Resident #8 (R-8). R-1 is not longer residing at this location. Staff interviews revealed that staff are not withholding food from residents. Staff interviews revealed that they have not observed staff nor have they received any complaints from anyone in regards to staff withholding food from residents. Resident interviews revealed that facility staff do not withhold food from them. Per LPA Miramontes' investigation, "Investigation revealed the following: Administrator denied that staff withheld food from R1 or from any other resident in care". Staff and Resident interviews do not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 28-AS-20190923172523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044
VISIT DATE: 08/11/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Facility served spoiled food to resident.
During today's investigation, LPA Irra interviewed the Facility Administrator and Staff #1 (S-1) through Staff #4 (S-4). LPA also interviewed Resident #2 (R-2) through Resident #8 (R-8). R-1 is not longer residing at this location. Staff interviews revealed that staff do not serve spoiled food to residents. Staff interviews revealed that they have not observed staff nor have they received any complaints from anyone in regards to staff serving spoiled food to residents. Resident interviews revealed that facility staff does not provide them with spoiled food. Per LPA Miramontes' investigation, Administrator also denied that facility serves spoiled food to residents. Staff and Resident interviews do not corroborate this allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and Appeal Rights provided to the Facility Administrator
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/23/2019 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20190923172523

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: 85DATE:
08/11/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Faciltiy AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights: Resident sustained an unexplained fall causing injuries
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced visit to obtain additional information for the above allegation. LPA met with the Facility Administrator and discussed the purpose of today's visit. During today's visit, LPA Irra obtained documentation which supports LPA Miramontes' finding.

The investigation for the above allegation was conducted by LPA Juan Pablo Miramontes. LPA Miramontes conducted visits on the following dates: 09/26/2019, 10/25/2019 and 11/22/2019. On 11/22/2019, LPA Miramontes provided the following to the Facility Administrator: Licensing Program Analyst (LPA) Juan Pablo Miramontes conducted a subsequent complaint investigation visit to Vista Veranda Assisted Living on 11/22/2019 to gather further information for the allegation mentioned above. LPA was met by Administrator Marcella Calvillo and informed of the nature of today's visit.

Refer to LIC 9099C for the continuation of this report.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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 8
Control Number 28-AS-20190923172523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044
VISIT DATE: 08/11/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Miramontes investigation continuation:
Investigation consisted of the following: Review of complaint report, review of resident #1(R-1) facility record files, which included but not limited to Admissions Agreement, Physician's Report and Medical Discharge Documents. Interview with Administrator Calvillo and with Staff #1 and family member.

Investigation revealed the following: According to Physician's Report Resident #1 (R-1) is non- ambulatory, but during interview family admitted that R-1 is ambulatory and arrived to the facility without any wheelchair or assistive devices for walking. Facility staff indicated that R-1 did not arrive to the facility with any wheelchair or assistive devices for walking. Facility staff also indicated that R-1 was ambulatory.

R-1 was admitted to the facility on 09/14/2019 at approximately 12 noon and facility provided LPA with documents from hospital dated 09/14/2019 and printed on 09/15/2019 at 2:33AM indicating that R-1 was hospitalized after being admitted to facility. The reason for hospitalization was for an unexplained fall while in care at the facility with injury. Facility staff stated during interview that R-1 did fall, but could not explain the fall. Facility staff did not report fall with injury or hospitalization for R-1 to the licensing agency as required.

Based on LPA’s observations and interviews which were conducted and records 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, Chapter 8, is being cited on the attached LIC 9099D.

Exit interview conducted and Appeal Rights were provided to Facility Administrator
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 28-AS-20190923172523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2021
Section Cited
HSC
1569.312(e)
1
2
3
4
5
6
7
§1569.312 - Basic Services Requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
1
2
3
4
5
6
7
Licensee/Administrator to ensure that adequate monitoring of activities of the residents while under facility supervision is provided especially to those residents with dementia to ensure their general health, safety and well-being, by having an in-service with all memory care staff responsible for the care and supervision of residents by providing a sign-in
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Disclosure by facility staff that resident had an unexplained fall that caused injury and was hospitalized.
8
9
10
11
12
13
14
sheet with printed and signed names of participating staff and provide an LIC500 to LPA by the POC due date of 08/18/2021 via email or fax.
Type B
08/18/2021
Section Cited
CCR
87211(a)(1)(B)
1
2
3
4
5
6
7
87211 - Reporting Requirements: (a) Licensee shall furnish the licensing agency such reports as the Dept. may require, including, .... following: (1) A written report shall be submitted to the agency w/in 7 days of occurrence of any...events specified in (A)-(D). This report shall...
1
2
3
4
5
6
7
Licensee/Administrator shall provide Licensing Agency with reports as required for any events as specified in 87211. Administrator to submit a written statement as to how Administrator will adhere to this section of the regulations.
8
9
10
11
12
13
14
(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.

This requirement not met as evidenced by: Incident occurring on 09/14/19 was not reported to the licensing agency.
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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 8