197608044-12-3-2021-11-AS-JHAD-C9G36G-20211206165818

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 12/01/2021
Date Signed: 12/03/2021 04:05:23 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
10/12/2021 and conducted by Evaluator Ulysses Coronel

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211012112144

FACILITY NAME:	VISTA VERANDA ASSISTED LIVING		FACILITY NUMBER:	197608044
ADMINISTRATOR:	YVETTE LEM		FACILITY TYPE:	740
ADDRESS:	3540 MARTIN LUTHER KING, JR.		TELEPHONE:	(310) 638-4113
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY:	178	CENSUS: 79	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	11:03 AM
MET WITH:	Nishith Modi		TIME COMPLETED:	11:31 AM

ALLEGATION(S):

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Resident sustained fracture while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegation 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 10/14/2021 LPA Coronel conducted review of the incident report submitted by the facility. On 10/21/2021 LPA Coronel and LPA Gail Johnson initiated a Complaint Investigation visit, LPA’s conducted a tour of the facility, interviewed administrator, 4 staff and 10 residents. LPA Coronel obtained copies of facility and resident records. On 10/21/2021 LPA conducted review of R1 hospital medical records. On 10/22/2021 LPA interviewed witness W1. On 10/29/2021 LPA Coronel interviewed Staff S5, S6, LVN1 and LCG1. On 11/01/2021 LPA Coronel conducted a review of R1’s resident records. On 11/08/2021 LPA Coronel interviewed staff S7 and S8. On 11/15/2021 LPA Coronel conducted reviews of regional office, facility and resident R1’s 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: 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-20211012112144

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; “Resident sustained fracture while in care.” Record reviews indicate the following: The Physician's Report indicate that; On 02/15/2021 R1's primary diagnosis is Dementia and secondary is HTN. Mental Condition - Confused, Able to communicate needs. Ambulatory Status - Ambulatory, able to independently transfer to and from bed. The Needs and Services Plan indicate that; On 04/13/2021 resident R1 is identified as at risk for falls due to confusion, gait problems. The plans goal is for R1 to have a reduction in the number of avoidable falls. The plans interventions are to encourage, remind and assist R1 with using the bathroom at more frequent intervals. Remind R1 to rise and change positions slowly, e.g. arising from a chair, bed. The Unusual Incident/Injury Report indicate that; On 10/11/2021 around 5pm, R1 was observed laying on the floor by staff S1. LVN1 assessed R1 reported that R1 did not show immediate discomfort or pain. LVN1 set up a non-emergency transport to take R1 to the hospital. The facility’s Daily Census indicate that; On 10/11/2021 Vista Veranda's Daily Census Report indicate that R1 along with 27 other residents were staying at the facility’ first floor Memory Care Unit (MCU1). On 10/21/2021 reviews of R1’s hospital medical records indicate that; On 10/12/2021 at 3:20am R1 was admitted at Norwalk Community Hospital via non-emergency ambulance for evaluation of right hip and pelvic pain. R1 was diagnosed with Hypertension and Fracture of right hip, On 10/19/2021 R1 underwent surgery for right hip fracture.
Facility staff and witness interviews revealed the following: S1 stated that: I was inside the storage room helping another resident change their clothes when I heard someone fell, it sounded like someone fell. I immediately came to see, and I saw R1 on the floor. Then I called LVN1 for help. After dinner we noticed that R1 was not able to stand. We put R1 on a wheelchair, then the three of us S5, S6 and I helped R1 from the wheelchair to the bed. At 7pm I changed R1’s diapers, R1 was wincing and complained that it hurts, I told LVN1 about it.". S5 and S6 denied witnessing R1 fall, both caregivers stated they were assisting other residents with their showers. LVN1 stated that “Around 5:30 R1 was observed in pain while eating dinner.” “The transportation company told us that they were backed up and that it would take a while." And “I believe the transportation arrived around 1(am).” Staff S8 stated that: "All I know I found out from the other staff. They told us that it was not anything serious and that they already called for an ambulance. We (11pm to 7am staff) were looking constantly over R1, we were hearing R1 complain but we had already heard that the ambulance was coming through at night. It was around 1:00am, the ambulance came around 30 minutes later." Regarding the allegation; “Resident sustained fracture while in care.” the preponderance of evidence standard has been met therefore the above allegation is found to be substantiated. California Code of Regulations, Tittle 22, division 6 are being cited please see LIC 9099D.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (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-20211012112144

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
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	An immediate civil penalty is being assessed for a repeat violation of Health and Safety Code 1569.312(e) within 12 months please see LIC421IM. 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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (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: 3 of 4

Control Number 11-AS-20211012112144

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 HSC 1569.312(e)	1 2 3 4 5 6 7	§1569.312 (e) Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee will create a plan to ensure 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. Proof of correction will be submitted by POC due date.
	8 9 10 11 12 13 14	Based on record reviews and interviews conducted the licensee failed to ensure that residents were monitored, R1 had an unsupervised fall resulting to injury and hospitalization. This poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
Type B 01/03/2022 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee will create a plan to ensure that 9-1-1 is called if an injury or other circumstance has resulted in an imminent threat to a resident’s health. Proof of correction will be submitted by POC due date.
	8 9 10 11 12 13 14	Based on record reviews and interviews conducted the licensee failed to ensure that 9-1-1 was called, R1 complained of pain between 5:30pm and 1:00am after an unwitnessed fall that resulted to injury and hospitalization. This poses an immediate risk to the health and safety of 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: 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)

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