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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 12/01/2021
Date Signed: 12/02/2021 01:39:42 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
07/07/2021 and conducted by Evaluator Ulysses Coronel
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210707110532
FACILITY NAME:VISTA VERANDA ASSISTED LIVINGFACILITY NUMBER:
197608044
ADMINISTRATOR:YVETTE LEMFACILITY TYPE:
740
ADDRESS:3540 MARTIN LUTHER KING, JR.TELEPHONE:
(310) 638-4113
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:178CENSUS: 79DATE:
12/01/2021
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:NIshith ModiTIME COMPLETED:
11:04 AM
ALLEGATION(S):
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Facility staff withheld money from resident
Facility staff misused resident's money
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegations listed above. Today’s complaint investigation was conducted telephonically with Licensee Representative Kinal Modi and Administrator Nishith Modi.

The investigation consisted of the following: On 07/09/2021 LPA Coronel conducted a tour of the facility. LPA interviewed the administrator and 2 staff and 3 out of 90 residents. LPA reviewed resident records and requested copies of all SSI/SSP recipients Admission Agreements, Personal and Incidental (P&I) ledgers, Rent ledgers and (WF and F&M) Bank Statements for the last six months. On 08/10/2021 Licensing Program Manager (LPM) Hammond requested the Community Care Licensing Division’s (CCLD) Audit Section to conduct a Trust Audit. During the trust audit the General Auditor III (Auditor) Jessica Chen requested and viewed facility census/roster; Admission Agreements (AA); residents financial ledgers (LIC405) and bank records of 39 SSI/SSA recipient residents from January 2020 to July 2021. On 11/18/2021 CCLD’s Audit section has completed the trust audit.
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: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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 4
Control Number 11-AS-20210707110532
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: 12/01/2021
NARRATIVE
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The investigation revealed the following: Regarding the allegation; “Facility staff withheld money from resident.” On 11/18/2021 the CCLD Trust Audit revealed that the facility acted as the residents Creditor when the residents received reduced SSI payments and the facility continued to charge them the SSI or higher rate thus leaving their financial ledger with negative balances. The audit revealed that the facility owes 30 out of 39 resident’s P&I money totaling to over $42,000.00. The Auditor’s review of 39 residents; Admission Agreements, financial ledgers, P&I ledgers and invoices revealed that the facility charged residents R1, R2, R4, R6, R7, R8, R9, R10, R11, R14, R15, R15, R16, R17, R18, R19, R21, R22, R23, R24, R26, R28, R29 & R39 $1,500.00 per month and charged residents R5, R30, R31, R33, R36 & R37 $1,800.00 per month for board and care (B&C) which exceeds the SSI established B&C rates of $1,069.37 for year 2020 and $1,079.37 for year 2021. Regarding the allegation “Facility staff withheld money from resident.”; 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.

Regarding the allegation; “Facility staff misused resident's money.” On 11/18/2021 the CCLD Trust Audit of 39 residents; Admission Agreements, financial ledgers, P&I ledgers and invoices revealed that $20.00 of residents exempt income were being used to pay for basic services without proper support on the residents Admission Agreements. The facility failed to give $20 of exempt income to residents R1, R3, R11, R16, R18, R20, R21, R23, R24, R26, R28, R2 & R25. Regarding the allegation; “Facility staff misused resident's money.”; 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 developed. A copy of this report and appeals rights were provided for signature.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20210707110532
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: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2022
Section Cited
CCR
87468.2(a)(8)
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87468.2(a)(8) Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents... rights: To be free from neglect, financial exploitation,... abuse. This requirement was not met as evidenced by:
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The licensee will create a plan to address overcharges made to resident’s P&I money totaling to over $42,000.00. Proof of correction will be submitted by POC Due date.
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Based on record reviews the licensee failed to ensure that residents are free from financial exploitation, the facility charged residents higher than the set rate, leaving resident financial ledger with negative balances which poses a potential risk to the health and safety of residents in care.
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Type B
01/03/2022
Section Cited
CCR
87464(e)
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87464(e) Basic Services. If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made available at the basic rate at no additional charge to the resident. This requirement was not met as evidenced by:
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The licensee will create a plan to ensure that SSI/SSP recipient residents are charged at the basic rate per annual SSI/SSP Payment Standards. Proof of correction will be submitted by POC Due date.
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Based on record reviews, the licensee failed to ensure that basic services are provided at no additional costs to SSI/SSP recipients, the facility charged residents more than the SSI/SSP payment standards 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: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20210707110532
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: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2022
Section Cited
CCR
87507(g)(3)(A)(3)
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87507(g)(3)(A)(3) Admission Agreement, Admission agreements shall specify the following: Payment provisions, including the following: Basic services rate(s), including: Exempt-income-allowance may be included if the resident agrees to such charge.
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The licensee will create a plan to specify $20.00 Exempt-income-allowance charges and provide the residents option to agree with such charges on Admission Agreements. Proof of correction will be submitted by POC Due date.
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Based on record reviews the licensee failed to ensure that the Admission Agreements indicates the residents right to agree or reject to credit $20.00 towards B&C, which poses a potential risk to 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: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4