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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 07/12/2022
Date Signed: 07/12/2022 05:05:27 PM

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
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/07/2022 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220707083535
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: 71DATE:
07/12/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Modi NishithTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff pushed resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced initial 10-day complaint visit to the above facility to investigate allegation. LPA was met by Administrator, Modi Nishith and the purpose of the visit was explained.

Investigation consisted of the following: On 7/12/22, LPA conducted interviews with administrator, staff #1-#5 (S1-S5), residents #1-#6 (R1-R6), requested recent incident reports pertaining to the above allegation, obtained staff S1 and S2 records, staff & resident roaster.

The investigation revealed the following:

Allegation: Staff pushed resident while in care.

LIC 9099-C is on the next page
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
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 2
Control Number 11-AS-20220707083535
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: 07/12/2022
NARRATIVE
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On 7/12/22 LPA interviewed the administrator regarding the allegation, he stated there was no incident that involved a staff member pushing in the facility. He stated no residents or staff brought to his attention any concerns. LPA conducted interviews with S1-S5, they stated have not pushed or handle any of the residents in a rough manner while in care. Staff stated they have not witnessed any staff handle residents in a rough manner. Interviews with R1-6 stated, staff hasn’t pushed them or been handle in a rough matter. Based on interviews conducted there is insufficient evidence to support the allegation.

Although the allegation is valid or may have happened there is insufficient evidence to support the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted and a copy of the report was provided to Modi

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2