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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 03/03/2022
Date Signed: 03/03/2022 03:38:45 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
12/20/2021 and conducted by Evaluator Ulysses Coronel
COMPLAINT CONTROL NUMBER: 11-AS-20211220095138
FACILITY NAME:VISTA VERANDA ASSISTED LIVINGFACILITY NUMBER:
197608044
ADMINISTRATOR:NISHITH MODIFACILITY TYPE:
740
ADDRESS:3540 MARTIN LUTHER KING, JR.TELEPHONE:
(310) 638-4113
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:178CENSUS: DATE:
03/03/2022
UNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:Nishith ModiTIME COMPLETED:
04:08 PM
ALLEGATION(S):
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Facility is not assisting resident in maintaining physical conditioning.
Staff are not providing adequate nail care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a subsequent 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 12/21/2021 LPA conducted a tour of the facility, interviewed Administrator and Activity and obtained copies of facility and resident records. On 02/15/2022 LPA Coronel and LPA Jeremiah Randle conducted a tour of the facility, LPAs interviewed the administrator, 4 staff and 8 out of 73 residents. On 02/28/2022 LPA Coronel conducted a review of the facility’s Personnel Report and Activity Calendar.

The investigation revealed the following: Regarding the allegation “Facility is not assisting residents in maintaining physical conditioning.” On 02/28/2022 LPA reviewed the facility’s Personnel report and only observed 1 staff assigned to conduct resident activities. On 02/15/2022 S1 stated “I'm not familiar on who is in-charge of maintaining residents physical conditioning, I have not tried to do it on the Memory Care Unit side. I am not able to do a lot of activities, but if I had another assistant then I would be able to finish the activities."
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: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
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 5
Control Number 11-AS-20211220095138
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: 03/03/2022
NARRATIVE
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During interviews 2 out of 8 residents interviewed disagreed with the allegation, R2 stated " They're good, S1 is trying. We have walk rounds. and exercise.", 3 out of 8 residents neither agreed nor disagreed with the allegation, R8 stated "I don’t join activities." 3 out of 8 residents agreed with the allegation, R10 stated “There are no physical activities being provided here.” Regarding the allegation “Facility is not assisting resident in maintaining physical conditioning” 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 LIC 9099D. This deficiency was cited on 05/24/2021 a civil penalty is being assessed for repeat violation. Please see attached LIC421FC.

Regarding the allegation: “Staff are not providing adequate nail care.” It is alleged that the facility cut the residents nails poorly. On 02/15/2022, 2 out of 4 staff interviewed agreed with the allegation, S2 stated “The caregivers are not provided with nail clippers." 2 out of 4 staff interviewed neither agreed nor disagreed with the allegation, S4 stated "I don't know." 2 out of 8 residents disagreed with the allegation, R2 stated “I've seen caregivers clip some residents nails." 5 out of 8 residents neither agreed nor disagreed with the allegation, R10 stated “I'll do that myself, I just don't have a clipper." Regarding the allegation: “Staff are not providing adequate nail care.” 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 LIC 9099D.

Plans of correction were developed, and an exit interview was conducted. A copy of this report and appeals rights were provided with Nishith Modi, administrator.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20211220095138
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: 03/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited
CCR
87219(f)
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87219(f) Planned Activities. In facilities licensed for fifty (50) persons or more, one staff member ... shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The... residents. The ... volunteers. This requirement was not met as evidenced by:
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The administrator agreed to create a plan to ensure that the Activity Director is given staff assistance as necessary for all residents to participate in accordance with their interests and abilities. Proof of correction will be submitted by POC due date.
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Based on record reviews and interviews conducted the licensee failed to ensure that activities staff is given staff assistance as necessary in for all residents to participate in accordance with their interests and abilities. The Activity Director is not provided with additional staff assistance which poses a risk to the health and safety of residents in care.
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Type B
03/10/2022
Section Cited
CCR
87307(a)(3)
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Personal Accommodations and Services. Living... function. The...facility. The...apply: Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The... licensee shall assure provision of: This requirement was not met as evidenced by:
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The administrator agreed to create a plan to ensure that residents are provided with adequate nail care. Proof of correction will be submitted by POC due date.
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Based on interviews and obsevation the licensee failed to supply necessary for personal care and maintenance of adequate hygiene practice are readily available to each resident. The facility did not provide nail clippers to staff & residents to ensure adequate nailcare practice are made which poses a 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: 03/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
12/20/2021 and conducted by Evaluator Ulysses Coronel
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20211220095138

FACILITY NAME:VISTA VERANDA ASSISTED LIVINGFACILITY NUMBER:
197608044
ADMINISTRATOR:NISHITH MODIFACILITY TYPE:
740
ADDRESS:3540 MARTIN LUTHER KING, JR.TELEPHONE:
(310) 638-4113
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:178CENSUS: DATE:
03/03/2022
UNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:TIME COMPLETED:
04:08 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not assisting resident with hygiene needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ulysses Coronel initiated a subsequent 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 LPA Coronel conducted a tour of the facility, interviewed Administrator and 2 staff. LPA also obtained copies of facility records. On 12/21/2021 LPA conducted a tour of the facility, interviewed Administrator and Activity Director and obtained copies of facility and resident records. On 02/15/2022 LPA Coronel, LPA Jeremiah Randle conducted a tour of the facility, LPAs interviewed the administrator, 4 staff and 8 out of 73 residents. On 02/28/2022 LPA Coronel conducted a review of the facility’s Personnel Report and Activity Calendar.

The investigation revealed the following: Regarding the allegation “Staff are not assisting resident with hygiene needs.” On 12/21/2021 LPA conducted a tour of the facility and observed that resident R1 had no facial hair and wore clean clothes.
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: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20211220095138
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: 03/03/2022
NARRATIVE
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On 02/15/2021 LPA conducted a tour of the facility and observed that resident R1 had no facial hair and wore clean clothes. On 02/15/2022 4 out of 4 staff disagreed with the allegation, S2 stated “Sometimes residents refuse, then we try to help them the next day." During interviews 3 out of 8 residents interviewed agreed with the allegation, R2 stated “You can smell them and the smell is offensive.", 5 out of 8 residents disagreed with the allegation, R3 stated “The staff do remind you when you need to take a bath. Sometimes residents just refuse". Regarding the allegation “Staff are not assisting resident with hygiene needs.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

A copy of this report was provided with Nishith Modi, administrator.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5