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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 12/07/2022
Date Signed: 12/08/2022 07:27:53 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
12/01/2022 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221201140337
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: 66DATE:
12/07/2022
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Nishith ModiTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Residents are nor provided proper food service
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 called administrator before entering the building and confirm there was no Covid-19 Cases. LPA was met by Administrator, Modi Nishith and the purpose of the visit was explained.

Investigation consisted of the following: On 12/7/22, LPA Brown toured the entire facility along with the administrator. LPA conducted interviews with administrator, staff #1-#5 (S1-S5), residents #1-#6 (R1-R6). LPA obtained the following documentation: Staff and resident roster.
The investigation revealed the following:

Allegation: Residents are nor provided proper food service

LIC 9099-C is on the next page
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/07/2022
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-20221201140337
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044
VISIT DATE: 12/07/2022
NARRATIVE
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On 12/7/22, it was alleged that resident are not allowed to eat in the dining room and can only eat in their rooms. It was also alleged that food is delivered late. LPA interviewed the administrator regarding the allegations, he stated resident are not allowed to eat in the dining room during this time due to the recent positive Covid-19 cases in the facility. He stated there was 6-7 positive cases. He stated testing was done on 11/30/22 and results were negative and today 12/7/22. He stated after 2 negative tests will open the dining room. He also stated residents are provided 3 meals and snacks daily and are delivered on time. LPA conducted interviews with staff members #2-#5, they all confirmed residents are not able to eat in the dining room due to recent Covid-19 cases. Staff stated all 3 meals including snacks are provided timely to residents and they have not heard any complaints. Staff also stated they were tested today. LPA conducted interviews with resident #1-#6. All residents confirmed they were not eating in the dining room due to the recent Covid-19 cases. Residents stated they receive all of their 3 meals on time and including snacks and haven't heard any complaints. Residents also stated they have received Covid-19 testing today. LPA also observed testing being conducted and reviewed Informational Calls and CCLD Provider Pins and did not see specifics regarding communal dining. 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 Nishith Modi

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

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

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