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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 12/13/2021
Date Signed: 12/16/2021 04:34:17 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
09/08/2021 and conducted by Evaluator Ulysses Coronel
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210908144759
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:
12/13/2021
UNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:NIshith ModiTIME COMPLETED:
06:02 PM
ALLEGATION(S):
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Staff abandoned resident.
Staff refusing to provide a refund to residents authorized representative.
Staff did not safeguard residents personal belongings.
Staff did not provided activities to resident.
Staff denied visitation for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a Complaint Investigation visit and met with Nishith Modi, the administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 09/14/2021 LPA Coronel conducted a tour of the facility, interviewed administrator and staff S2. And requested copies of resident and staff records. On 09/15/2021 LPA interviewed staff S3. On 11/08/2021 LPA conducted record reviews. On 12/13/2021 LPA conducted a tour of the facility, interviewed the administrator, 4 staff and 8 residents.

The investigation revealed the following: Regarding the allegation: Staff abandoned resident. On 09/08/2021 the department received the allegation which indicates that the facility didn’t go back and pick-up R1 from the hospital. On 09/15/2021 Staff S3 stated that: “After the hospital, R1 was taken to a skilled nursing facility for rehabilitation. I called R1’s responsible person but they didn't answer, so I left voice messages."
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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 6
Control Number 11-AS-20210908144759
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: 12/13/2021
NARRATIVE
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During today’s visit the administrator stated that “The hospital usually arranges transportation for the residents when they discharge residents back to this facility. From the hospital they discharged R1 to a skilled nursing facility.” Regarding the allegation: Staff abandoned resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation: “Staff refusing to provide a refund to residents authorized representative.” On 09/08/2021 the department received the allegation which indicates that the facility did not reimburse the rents paid while R1 was in the hospital even though R1 did not return to the facility. On 11/08/2021 record reviews indicate that R1 was taken to the hospital on 03/29/2021 and that R1’s responsible person has continued paying for rent for April, May and June of 2021. R1’s admission agreement indicates that “In the event of Resident's absence, with or without notice and for any reasons, Without removing his/her personal belongings from the unit, the Facility will hold the unit ("Bed Hold"), without renting it to other resident. for a maximum period of Three months. Resident shall be responsible for paying the monthly fee during the bed hold period.” Regarding the allegation: “Staff refusing to provide a refund to residents authorized representative.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation: “Staff did not safeguard residents’ personal belongings.” On 09/08/2021 the department received the allegation which indicates that R1 never had on any of the clothes bought for him by family. During todays visit S1 stated that “R1’s family got upset when they came here to get R1’s personal belonging, they wanted to get back the same exact clothes that they gave R1m, they refused to get the set of clothing’s in R1’s room. Due to their condition R1 soils their clothes while they are at their Day Program, when this happens the program would replace R1’s clothes with clean clothes and did not return the soiled clothes to us. S4 stated: “I told R1’s family that they did not have laundry at R1’s day program.” Regarding the allegation: “Staff did not safeguard residents’ personal belongings.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation: “Staff did not provided activities to resident.” On 09/08/2021 the department received the allegation which indicates that there were no activities being provided to residents. Around 9:30am during todays visit LPA observed around 10 residents gathering at the activity room and observed activity calendars and the activity schedule for the day posted.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20210908144759
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: 12/13/2021
NARRATIVE
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 LPA also conducted reviews on S2 notes regarding the activity breakdown for December 2021. S2 stated that “We offer residents social activities in the mornings and games or exercises activities in the afternoons. During todays visit 7 out of 8 residents interviewed did not have issues regarding the activities being provided, R2 stated “I think it’s a lot of fun, there are a lot of games.” 1 out of 8 residents said there were no activities being provided, R6 stated “What activities, there’s no activities.” Regarding the allegation: “Staff did not provided activities to resident.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation: “Staff denied visitation for resident.” On 09/08/2021 the department received the allegation which indicates that the facility was closed to visitors and no one told R1’s family that they could do visits by the window. During todays visit 8 out of 8 residents did not have any issues with the facilities visitation policy. The administrator stated that “There were no visitations allowed during the peak of COVID-19, residents were allowed to have window visits per family request only.” Regarding the allegation: “Staff denied visitation for resident.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted. A copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6
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
09/08/2021 and conducted by Evaluator Ulysses Coronel
COMPLAINT CONTROL NUMBER: 11-AS-20210908144759

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:
12/13/2021
UNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:NIshith ModiTIME COMPLETED:
06:02 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not meet residents hygeine needs
INVESTIGATION FINDINGS:
1
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5
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a Complaint Investigation visit and met with Nishith Modi, the administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 09/14/2021 LPA Coronel conducted a tour of the facility, interviewed administrator and staff S2. And requested copies of resident and staff records. On 09/15/2021 LPA interviewed staff S3. On 11/08/2021 LPA conducted record reviews. On 12/13/2021 LPA conducted a tour of the facility, interviewed the administrator, 4 staff and 8 residents.

The investigation revealed the following: Regarding the allegation: "Staff did not meet residents hygeine needs" On 09/08/2021 the department received the allegation which indicates that the facility failed to arrange haircuts for R1. During todays visit LPA observed 8 out of 8 residents denied being offerred haircuts at the facility, R5 stated "They used to have someone come in to give haircuts, it culd have been offerred last winter." S1 stated "The former administrator used to bring a hairdresser to provide residents haircuts for $20.00 dollars."
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: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20210908144759
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: 12/13/2021
NARRATIVE
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The administrator stated "We never offered haircuts to residents." R8 stated they used to offer haircuts here, I need one and would get one if they offered it." Regarding the allegation: "Staff did not meet residents hygiene needs" Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC9099D.

An exit interview was conducted, plans of corrections were developed. A copy of this report and appeals rights were provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20210908144759
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: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2022
Section Cited
CCR
87466
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87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When ...any. This requirement was not met as evidenced by;
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The administrator agreed to create a plan to ensure compliance with Title 22 regulation 87466 Observatiion of the Resident in providing assitance to residents that needs hairdresser services. Proof of correction will be submitted by POC due date.
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Based on observation and interviews conducted the licensee failed to ensure that residents are observed for physical changes and that appropriate assitance is provided, residents were not provided with assistance getting haircuts 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: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6