197608044-3-24-2023-11-AS-EMAZ-CRWPVS-20230517113937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 03/24/2023
Date Signed: 03/24/2023 03:43:58 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
05/16/2022 and conducted by Evaluator Martessa Brown

COMPLAINT CONTROL NUMBER: 11-AS-20220516151736

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: 64	DATE:	03/24/2023
		UNANNOUNCED	TIME BEGAN:	10:17 AM
MET WITH:	Patricia Garcia		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Administrator is not providing COVID-19 PPE for staff to care for residents
Facility elevator for residents is in disrepair

INVESTIGATION FINDINGS:

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On 3/24/23, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings for the above allegation. LPA confirmed there was no Covid-19 Cases or pending test results. During today’s visit LPA met with Patricia Garcia, Memory Care Supervisor and the purpose of the visit was explained.

The investigation consisted of the following: On 5/23/22 and 12/16/22 LPA met with Nishith Modi with the administrator and toured the facility. LPA conducted interviews with Administrator Staff Members #1-#6 and Residents #1-#4. LPA obtained and reviewed Staff and Residents. LPA also obtained copies of elevator invoices.

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: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

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-20220516151736

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: 03/24/2023

NARRATIVE

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The investigation revealed the following:

Allegation: Administrator is not providing COVID-19 PPE for staff to care for residents

It was alleged that the administrator Nishith Modi is not providing mask and gloves, for staff to be in compliance with CCL requirements to care for the residents. On 5/23/22 and 12/26/22, LPA conducted interviews with the Administrator Nishith Modi, Staff #1-#6 and Residents #1-5. On 5/23/22 and 12/26/22, LPA observed PPE supplies both locked in the supply room upstairs and in the medication room down stairs. During interviews conducted with 6 staff members all stated Administrator would not give them mask and will have to buy there own or will give them a hard time when asking for mask and glove. During interviews conducted with 4 residents, they stated were not given mask for a while. Based on the information gathered during this investigation, LPA found sufficient evidence to support that above mentioned allegation.

Allegation: Facility elevator for residents is in disrepair

It was alleged that the facility elevator is not operating, and the residents are complaining facility elevator was not working. On 5/23/22 and 12/26/22, LPA conducted interviews with the Administrator Nishith Modi, Staff #1-#6 and Residents #1-5. On 5/23/22 and 12/26/22. During visit on 5/23/22, LPA observed the elevator was in operation. During interview with the Administrator Modi, informed LPA that the elevator was not working for one day and was repaired. Interviews conducted with 6 staff informed elevator were not operating for 2 days. Interview with residents stated elevators were down during this time. Based on the information gathered during this investigation, LPA found sufficient evidence to support that above mentioned allegation.

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.

Exit interview was conducted and a copy of the report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20220516151736

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: 03/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/03/2023 Section Cited HSC 87470(a)(4)	1 2 3 4 5 6 7	87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows: (4) All facility staff and volunteers shall use gloves as a protective barrier to prevent the spread of potential infection as... This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator will review regulation and ensure staff will be provided PPE equipemnt to assist residents in care. Administrator will provide an outline they will ensure staff and residents are provided PPE's by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted, the facility failed to ensure staff was provided mask and gloves in order to assist residents in care during Covid-19. This poses a potential health and safety risk to all residents in care.	8 9 10 11 12 13 14	Adiministrator, staff and residents informed elvator was not operating. On 5/23/22 LPA observered elevator is now working . POC was cleared.
Type B 05/23/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by:	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	Based on interviews conducted, the facility elvators were not operating for 2 days. This poses a potential health and safety risk to all residents in care.	8 9 10 11 12 13 14

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: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC9099 (FAS) - (06/04)

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