197608044-4-5-2023-11-AS-MVAO-CQZRGM-20230418130059

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 04/05/2023
Date Signed: 04/05/2023 11:51:34 AM

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

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:	04/05/2023
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Patricia Garcia.-Memory Care supervisor		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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

INVESTIGATION FINDINGS:

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The purpose of this report is to clarify the allegation findings narrative documented in the report created on 1/9/2023. The “Substantiated” findings remain unchanged; however, this report was created on 4/5/2023 Supersedes the complaint investigation report created on 1/9/2023.

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 3/22/2023, LPA conducted an interview with Memory Care Unit Supervisor/ Patricia Garcia.

On 1/9/2023 the investigation consisted of the following: LPA Brown conducted a tour of the facility grounds, interviewed Residents R1-R2, administrator and staff S2-S4. LPA Brown obtained the following records for Residents #1-2: Physicians Reports, Pre-Admission Appraisal, Needs and Service Plan, and Unusual Incident Report related to the above allegation.
LIC 9099 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: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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: 04/05/2023

NARRATIVE

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The investigation revealed the following:

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

On 01/09/2023 and 03/22/2023, LPA conducted interviews with Residents (R1-R2), Administrator/ Nishith Modi (S1), Memory Care Unit Supervisor/ Patricia Garcia (S5) and Staff (S2-S4). LPA obtained Unusual Incident Report, Needs and Services Plan for R1-R2, and Physician Reports for R1-R2. During the course of this investigation, LPA found that on 1/2/2023, R1-R2 engaged in a physical altercation that took place on the Memory Care patio while unattended by staff. Staff did provide intervention after the physical altercation was occurring between R1-R2. As result of the altercation, 911 was called and R1 was taken to the hospital due a minor head injury. R1 was discharged from the hospital, after examination on 1/2/2023. LPA conducted an interview with Memory Care Unit Supervisor/Garcia who stated prior to the incident on 1/2/2023, there was tension for several days between R1 and R2 leading up to the physical altercation. Memory Care Unit Supervisor/Garcia also stated, there was an awareness that R1 and R2 do experience aggressive behaviors (i.e., verbal and physical). Based on the information gathered during this investigation, LPA found sufficient evidence to support that above mentioned allegation.

Based on interviews conducted with administrator, staff and records review, 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.

An exit interview was conducted an a copy of the report was given to Patricia Garcia.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 04/05/2023

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: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

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