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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 01/19/2023
Date Signed: 01/19/2023 03:56:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230117123438
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:
01/19/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator ModiTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility staff are not providing medication to resident(s) as needed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannouced 10-Day complaint visit to investigate the above allegation. The purpose of the visit was discussed with Administrator Modi.

The investigation consisted of: Tour of interior of facility, Memory Care Unit, Staff interviews (S1- S6),and Resident interviews (R1-R8). The following documents were obtained: R1- R8 Face sheet, LIC 500, and Resident Roster.

See LIC 9099C for report continuation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 313-3425
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
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 3
Control Number 11-AS-20230117123438
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044
VISIT DATE: 01/19/2023
NARRATIVE
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Allegation: “Facility staff are not providing medication to residents(s) as needed.” Based on record review and interviews conducted, the findings indicate that residents do receive their medications in a timely manner. According to staff interviews, Administrator Modi admitted to LPA that sometimes due to short staffing, medication isn’t always given or given in a timely manner. Administrator Modi admitted that on 01-17-23 and 1-18-23 he administered medication to residents due to staffing shortage. LPA observed no Med-Tech on duty at 2pm when their shift is to start.

Seven (7) out of the eight (8) residents interviewed all confirmed that their medications are sometimes skipped or given late due to Med-techs not available. This poses an immediate health, safety, or personal rights risk to persons in care.

Per Title 22, Division 6, Chapter 8, Article 08. Residents Assessments, Fundamental Services and Rights. 87465(a)(4) Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed.

Based on interviews the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8, Article 08.

See LIC 9099D

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 313-3425
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230117123438
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.
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Administrator will ensure medications prescribed by a licensed physician are given in accordance to prescription. Administrator will develop a plan to address staffing shortage and maintain temporary staffing that is trained to administer medication until permanent staffing is in place.
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This requirement was not met evidenced by:
Staff and resident interviews confirm staff is not administering medication in a timely manner.
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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: Tony VasalloTELEPHONE: (323) 313-3425
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3