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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 08/23/2023
Date Signed: 08/23/2023 02:33:28 PM


Document Has Been Signed on 08/23/2023 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



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: 63DATE:
08/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator - Jesse Loera MotaTIME COMPLETED:
02:30 PM
NARRATIVE
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On 08/23/2023, Licensing Program Analysts (LPA) Socorro Leandro along with Licensing Program Manager (LPM) Ulysses Coronel conducted an unannounced Case Management-Deficiency visit to document deficiencies observed during a case management visit on 08/16/2023 at this facility. The team met with Jesse Mota and explained the purpose of the visit.

On 08/16/2023 Nishith Modi stated that Vista Veranda has not issued any reimbursements to the residents indicated in the Trust Audit related to Complaint #11-AS-20210707110532. On 08/17/2023 LPM Coronel reviewed Nishith's appeal letter dated 03/25/2022 which indicated that facility was going to pay 28 out of 39 residents as decided by the Auditor.

On 08/16/2023 LPA Dabuet conducted resident record reviews and observed that two residents diagnosed with dementia (R1 and R2) did not have updated medical assessment on file. Records were dated 02/15/21.

On 8/16/2023 LPA Dabuet conducted personal record reviews and observed that two caregiver staff members (S1 & S2) had expired first aid certificates on file.

On 08/17/2023 LPM Coronel interviewed Nishith Modi via telephone, Nishith stated that Administrator Mota does not have access to all residents P&I / finances and does not have access to Personnel Records.

Deficiencies are being cited from Tittle 22 Regulations. An exit interview was conducted and plans of corrections were developed. Appeals Rights and a hard copy of this report was provided with Jesse Mota.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 08/23/2023 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2023
Section Cited
CCR
87405(d)(3)

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Administrator - Qualifications and Duties. The administrator shall have the qualifications...(7). If...apply. Ability to maintain or supervise the maintenance of financial and other records.
This requirement was not met as evidenced by:
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During today's visit LPA & LPM noticed that administrator now has access to files correction was observed in todays visit. The administrator agrees to maintain independent access to residents personal and incidential (P&I) records and personnel records to ensure future compliance.
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Based on interviews the licensee failed to ensure that the administrator Jesse Mota has the ability to maintain or supervise the maintenance of financial and personal records. Which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/30/2023
Section Cited
CCR87217(g)(1)(A)

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Safeguards for Resident Cash... Valuables. Each licensee shall maintain ... accurate records...following: Records...order. Each accounting shall be kept current. An...include: "(full signature of resident) ... from (payor)". This requirement was not met as evidenced by:
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The administrator agreed to reimburse the residents indicated in the Trust Audit related to Complaint #11-AS-20210707110532. Proof of correction will be submitted to CCL via email at Socorro.Leandro@dss.ca.gov.
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Based on interviews conducted the licensee failed to provide reimbursements to the residents indicated in the Trust Audit related to Complaint #11-AS-20210707110532. Which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/23/2023 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2023
Section Cited
CCR
87705(c)(5)

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Care of Persons with Dementia(c) Licensees...shall be responsible for ensuring the following:(5)...an annual medical assessment...a reappraisal done at least annually...shall include...resident’s dementia care needs. This requirement was not met as evidenced by:
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The administrator agreed to obtain a medical assessment for R1 & R2 and will create a plan to ensure that each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment.
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Based on record reviews the licensee failed to ensure that residents who are diagnosed with dementia (R1 and R2) obtained an annual medical assessment. Which poses/posed a potential health, safety or personal rights risk to persons in care.
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Proof of correction will be submitted to CCL via email at Socorro.Leandro@dss.ca.gov. The administrator may ask for an extension if more time is needed via email.
Type B
08/31/2023
Section Cited
CCR87411(c)(1)

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All RCFE staff...shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
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The administrator agreed to obtain current first aid certificates for S1 and S2 and will create a plan to ensure that ensure that caregiver staff who assist residents with personal activities of daily living receive annual first aid training.
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Based on record reviews S1 and S2 had expired first aid certificates on file. Which poses/posed a potential health, safety or personal rights risk to persons in care.
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Proof of correction will be submitted to CCL via email at Socorro.Leandro@dss.ca.gov. The administrator may ask for an extension if more time is needed via email.
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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3