197608044-12-22-2021-11-AS-UCOL-C9XMAA-20211222082558

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 12/21/2021
Date Signed: 12/22/2021 08:26:56 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 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: 78	DATE:	12/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	NIshith Modi		TIME COMPLETED:	12:17 PM

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	Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Name, Title and the purpose of today’s visit was explained. The facility is licensed to serve residents age range 60 and over. 4 non-ambulatory of which 1 may be bedrriden.. There are currently 81 residents in placement. All (4) clients are ambulatory. The facility is a single story structure located in a residential neighborhood. It consists of the following: living room, kitchen, dining room, two (2) resident bedrooms, two (2) bathrooms with a two car attached garage and patio with chairs. LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 105.1F.A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

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: 12/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above The hot water temperature measured at 122.5 F in room 23 and 139.6 F in room 31, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/22/2021
	Plan of Correction
1 2 3 4	The administrator will create a plan to ensure that the water temperature controls will be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). Proof of correction will bne submitted to the departemednt within 24 hours.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 12/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: 12/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above, routine symptom screening (+/- temperature and symptom check) has not been initiated at entry for all staff, residents, and visitors, during todays visit LPA did not observe consistent documentation of visitors symptom checks, Staff S1 stated confirmed that staff are not able to consistently conduct symptom checks with visitors, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/11/2022
	Plan of Correction
1 2 3 4	Administrator will conduct an in service training with staff to ensure that routine symptom screening (+/- temperature and symptom check) is initiated at entry for all staff, residents, and visitors. Proof of correction will be submitted by POC Due Date.

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in during todays visit LPA observed that the window blinds in bedroom 21 are all missing and the light fixture in room 23 is busted which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/11/2022
	Plan of Correction
1 2 3 4	The administrator will create a plan to ensure that the faility is in good repair at all times and have the window blinds in bedroom 21 and the light fixture in room 23 repaired. Proof of correction will be submitted by POC due date.

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: 12/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 3 of 6

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: 12/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in LPA observed that the screen doors in room 32, 21 and Memory Care Unit Activity Room are in disrepair which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/11/2022
	Plan of Correction
1 2 3 4	The administraor will create a plan to ensure that all window screens are maintained in good repair and have the screen doors in room 32, 21 and Memory Care Unit Activity Room repaired. Proof of corrections will be submitted by POC due date

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above LPA observed that exits leading to the atrium form bedrooms 31 and 32 are being blocked by resident’s beds, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/11/2022
	Plan of Correction
1 2 3 4	The administrator will create a plan to ensure that all indoor passageways and stairways shall be kept free of obstruction. Proof of correction will be submitted by POC due date.

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: 12/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 4 of 6

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: 12/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above LPA did not observe a minimun of one weeks supply of non perishable food. Kitchen Supervisor S2 stated and showed documentation that the facility has enough non perishable food to last for another 4 days only, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/11/2022
	Plan of Correction
1 2 3 4	The administrator will create a plan to ensure that Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. Proof of correction will be submitted by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 12/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 5 of 6

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
	VISIT DATE: 12/21/2021

NARRATIVE

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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

The following deficiencies were observed during todays visit: The hot water temperature measured at 122.5 F in room 23 and 139.6 F in room 31. LPA did not observe consistent documentation of visitors symptom checks, Staff S1 stated confirmed that staff are not able to consistently conduct symptom checks with visitors. LPA observed that the window blinds in bedroom 21 are all missing and the light fixture in room 23 is busted. LPA observed that the screen doors in room 32, 21 and Memory Care Unit Activity Room are in disrepair. LPA observed that exits leading to the atrium form bedrooms 31 and 32 are being blocked by resident’s beds. LPA did not observe a minimum of one weeks supply of non perishable food. Kitchen Supervisor S2 stated and showed documentation that the facility has enough non perishable food to last for another 4 days only.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC809D. California Code of Regulations Section 87303(a) and 87468.1(a)(2) were cited again within 12 months, civil penalties are being assessed please see LIC421IM.

An exit interview was conducted and plans of corrections were developed. A copy of this report and appeals rights were provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 6 of 6