197608044-1-9-2023-11-AS-MVAO-CQZRGN-20230418130059

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 01/09/2023
Date Signed: 01/09/2023 05:23:30 PM

Substantiated

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
01/04/2023 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230104170840

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: 66	DATE:	01/09/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Nishith Modi		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident engaged in a physical altercation with another resident in care.

INVESTIGATION FINDINGS:

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On 1/9/2023 Licensing Program Analyst (LPA) Martessa Brown conducted an initial complaint investigation to address the allegation listed above. LPA Brown called and spoke to Administrator and confirmed no Covid-19 Cases at the facility. LPA met with Nishith Modi, Administrator and explained the purpose of this visit is to gather information for the complaint and deliver findings.

On 1/9/2023 the investigation consisted of the following: LPA Brown conducted a tour of the facility grounds, interviewed administrator and staff members S2-S4 and Residents R1-R2. LPA brown reviewed records and delivered findings. LPA obtained the following documents: Resident and Staff Roster, residents #1-2 File, most recent physicians Reports, Appraisal & needs and service. Incident reports related to above allegation and any pictures.

The investigation revealed the following:

LIC 9099-C is on the next page.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023

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-20230104170840

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: 01/09/2023

NARRATIVE

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Regarding the allegation: Resident engaged in a physical altercation with another resident in care. It’s being alleged that a resident was seen at the hospital for facial pain after altercation. Resident #1-2 were involved in a physical altercation while in memory care. 1/9/2023 conducted interview with administrator stated, Incident took place on 1/2/2023 but was not there during the altercation between R1 and R2. Administrator stated was told by staff members that R1-R2 had a fist fight on the patio and 911 was called and transported R1. Interviews with S2-S4 confirmed R1 had been agitating R2. During lunch time R1 and R2 were smoking on the patio by themselves. Staff stated R2 had punched R1 and also had scratches on the neck and bruising to the head and some bleeding. S2-S4 stated they had to separate R1-R2. All staff confirmed due to R1’s injuries had to be to transported to the hospital. LPA conducted Interview with R1 and stated “R2 had scratched and hit me. Look at my hand.” Interview with R2, did not confirm altercation. Interview with witness stated resident had x-ray’s and showed head injury and no loss of consciousness but was able to be discharge the same day.

During investigation, LPA reviewed the facility’s incident report stated at 12 pm there was an unwitnessed altercation between R1-R2. Resident R1 had been agitating R2 for several days and decided to punch R1. Report stated R1 had fell and hit head on the concrete. Incident had taken place in memory care unit in the main patio. R1 was transported to the hospital.

Based on the Documents, interviews conducted with administrator, staff and their confirmation of the allegation, and a review of the facility’s daily notes, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22 Division (6) and Chapter (8) are being cited on the attached LIC9099-D.

An exit interview was conducted with caregiver and a hard copy was provided with appeal rights.

See LIC 9009-D on the next page.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230104170840

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/17/2023 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3)To be free from punishment, humiliation, intimidation, abuse.... This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator will have staff review the regulation on personal rights section All staff must sign off indicating they have read and understand this regulation. Facility will also develop plan to ensure residents are free from any form of abuse from another resident, items must be submitted to licensing by POC due date1/17/23.
	8 9 10 11 12 13 14	Based on a review of records and interviews, the facility staff failed to ensure resident was free from being hit by another resident while in care. This poses a potential health and safety risk to all residents in care.	8 9 10 11 12 13 14
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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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023

LIC9099 (FAS) - (06/04)

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