197608044-3-28-2022-11-AS-AJKK-CDLW49-20220418165710

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 03/25/2022
Date Signed: 03/28/2022 08:28:22 AM

Unsubstantiated

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
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/18/2022 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20220318075107

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: 72	DATE:	03/25/2022
		UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Nishith Modi		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff failed to protect resident from being bullied
Staff failed to provide a safe and comfortable environment for resident in care

INVESTIGATION FINDINGS:

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On 3/25/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a 10-day complaint visit at this facility regarding the allegations mentioned above. LPA Montoya called and conducted a risk assessment with Administrator Nishith Modi. Shortly after, LPA met with Administrator Modi who assisted with the visit. The purpose of the visit was explained.

The investigation consisted of the following: LPA inquired questions relevant to the nature of the complaint. LPA Montoya conducted a tour of the facility. LPA Montoya interviewed the administrator, five (5) staff, and ten (10) residents. LPA requested and obtained copies of the staff roster, client roster, Resident #1’s and Resident #2’s service records (Identification and Emergency Information, Physician’s Report, Needs & Services/Reappraisal).

Report continued in LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220318075107

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
MONTERY PARK, CA 91754

FACILITY NAME: VISTA VERANDA ASSISTED LIVING	FACILITY NUMBER: 197608044
	VISIT DATE: 03/25/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff failed to protect a resident from being bullied

It was alleged that staff failed to protect Resident #1 (R1) from being bullied. The reporting party reported that Resident #2 (R2) has been bullying R1 for a long time. The RP also reported that on 3/17/2022 at 7:30 am, in the cafeteria, R2 pointed his finger towards R1 and made a hand gesture like a gun, and then went outside and told the other residents that he would kill R1. During the Interview, R1 stated R2 has been bullying and threatening her for the last two years but R1 does not want to report this bully/threat issue to the administrator.

Based on record review, Resident #1 (R1) was admitted to the facility on 9/10/2018. The physician’s report shows R1’s primary diagnoses are Diabetes II and Hypertension and R1’s secondary diagnoses are bipolar, schizophrenia, hyperlipidemia, and legal blindness. R1 is ambulatory. Needs and Services/Appraisal dated 5/7/2021 R1 sometimes has outbursts and the goal is to replace negative thinking with positive self-talk. With the physician’s order, R1 uses psychotropic medications for behavior management from schizophrenia and bipolar disorders.

LPA interviewed six staff (S1-S6), and ten (10) residents (R1-R10). LPA’s interviews with staff (S1-S6) and resident (R2-R10) revealed no resident is being bullied and threatened by another resident. Staff (S2, S3, S5, and S6) stated sometimes residents argue about little things and staff would immediately intervene and stop the argument. The administrator (S1) stated there are usually two (2) kitchen servers and one (1) or two (2) caregivers watching the residents in the cafeteria during mealtime. S1 revealed R2 is a quiet person and R2 does not have a record of bullying any resident. S2 stated R1 has a habit of complaining but R1 would take it back immediately and apologize. Based on observations, records reviews, and interviews, there are assigned staff to monitor residents while in a congregate, there may be some minor arguments between residents but there have been no incidents of resident bullying or threatening another resident. Based on information gathered, there is no sufficient evidence to corroborate the allegation above.

Report continued in LIC 9099C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220318075107

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
MONTERY PARK, CA 91754

FACILITY NAME: VISTA VERANDA ASSISTED LIVING	FACILITY NUMBER: 197608044
	VISIT DATE: 03/25/2022

NARRATIVE

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Allegation: Staff failed to provide safe and comfortable environment to residents in care

It was alleged staff failed to provide safe and comfortable environment to residents in care. LPA interviewed six (6) staff (S1-S6), and ten (10) residents (R1-R10). LPA’s interviews with staff (S1-S6), and nine (9) residents (R2-R10) revealed residents in care are safe and comfortable in the facility. R1 stated she does not feel safe and comfortable living in this facility but R1 would not state her reasons for feeling unsafe and uncomfortable. R1 stated however that she has been living in this facility since 2013 and she likes living at this facility.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, “Staff failed to protect resident from being bullied” and Staff failed to provide safe and comfortable environment to residents in care” did or did not occur, therefore the allegations are unsubstantiated.

No deficiencies cited, exit Interview conducted, and report given to Administrator Nishith Modi.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

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