197608044-6-21-2022-11-AS-UCOL-CHE27U-20220817170918

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 06/21/2022
Date Signed: 06/21/2022 04:08:51 PM

Substantiated

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
06/14/2022 and conducted by Evaluator Jey Cardenas

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220614094705

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: 70	DATE:	06/21/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Nishith Modi- administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not order refills for resident in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced initial 10 day complaint visit to the above facility to investigate allegation. Upon arrival at the facility LPA met with front desk staff and conducted a Covid-19 risk assessment, based on the assessment, the facility is clear of Covid-19 infection. LPA met with administrator, Modi Nishith and the purpose of the visit was explained.

Investigation consisted of: LPA conducted interviews with adminstrator, staff #1-#3 (S1-S3), residents#1-#7 (R1-R7), obtained staff/ resident roaster and facility documentation pertinent to the complaint allegation, & LPA toured plant.

It is alleged that: Staff did not order refills for R1 in a timely manner, therefore resident didn’t get medication for three (3) days and resident was in pain.

Per record review R1s Medication Administration Record (MAR) for month 6/01/22 to 6/30/22; LPA

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

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-20220614094705

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: 06/21/2022

NARRATIVE

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(continued pg2 )

observed that for medication oxycodone; dates 06/04/22, 06/05/22, 06/06/22 were left blank; there is no indication whether medication was administered, if resident was hospitalized, or if resident was not present at the facility. Oxycodone medication resumed again on 6/07/22. On 6/21/22 LPA observed R1s medication in the bubble packs and compared with MAR, no medication was missing at the time of visit. LPA saw that the medication Oxycodone bubble pack label shows date 6/06/2022 and the date opened was 06/07/2022.

Per LPA interviews, On 6/21/22 LPA Cardenas interviewed administrator, Modi Nishith who indicates that four(4) med-techs handle medication, med-techs call for refills in a timely manner. During interview with staff#1 it was indicated that only med-techs handle and refill medication. Med-techs will call five days prior to the medication running out to request a refill. S1 indicates that staff reorder medication in a timely manner. S1 denies that R1 missed oxycodone medication. S1 states there must have been an error documenting . During interview with R1 resident stated that they went three (3) days without getting pain medication, consequently and they were in pain. R1 stated that it is facility responsibility to communicate with the doctors to ensure medication is refilled. R2 indicates that they take sleeping pills every day; during one occasion staff didn’t administer the sleeping medication for one night, unsure the reason why it was not administered. R3 doesn’t take medication. R4 indicates there has been incidents where they don’t get their medication, no additional details. R5-R7 indicates medication is always available, refilled timely; and have not missed any doses.

Based on LPA’s observations, interviews, and record review(s), the preponderance of evidence standard has been met. Therefore, the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D. Exit interview conducted a copy of this report and appeal rights were provided to facility representative.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220614094705

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/21/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/22/2022 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	Incidental Medical and Dental. The licensee shall assist residents with self-administered medication as needed. This requirement is not met as evidenced by: Resident #1 did not receive their medication from 06/04/22 -06/06/22. This poses an immediate health and safety risk to residents in care.	1 2 3 4 5 6 7	Licensee shall provide additional training to all Staff responsible for medication refill and provide plan of training to the department by the POC date.
	8 9 10 11 12 13 14		8 9 10 11 12 13 14
Type A 06/24/2022 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Once ordered by the physician the medication is given according to the physician's directions. This requirement not met as evidenced by: On 06/04-06/06 R1 missed Oxycodone medication and was not given medication according to physician's direction. This poses an immediate health	1 2 3 4 5 6 7	Administrator will review title 22 regulations and submit self certification indicating that regulations were reviewed and understood.
	8 9 10 11 12 13 14	and safety risk.	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: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

LIC9099 (FAS) - (06/04)

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