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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 06/30/2023
Date Signed: 06/30/2023 01:28:25 PM

Unsubstantiated


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
06/27/2023 and conducted by Evaluator David Espana
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230627083750
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: 60DATE:
06/30/2023
UNANNOUNCEDTIME BEGAN:
08:06 AM
MET WITH:Jesse Loera-Mota, Administrator TIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Staff are not addressing resident’s medical needs
INVESTIGATION FINDINGS:
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On 06/30/2023, at 8:05 AM Licensing Program Analyst (LPA) David España met with Patricia Garcia, Supervisor and later met with Jesse Loera-Mota, Administrator to conduct a complaint investigation to address the allegations listed above. LPA España met with Jesse Loera-Mota, Administrator and explained the purpose of this visit.

The investigation consisted of the following: LPA España conducted a tour of the facility grounds. LPA España interviewed staff, clients, witnesses, and reviewed records. LPA España requested and reviewed the following documents, client roster, and staff roster, LIC 601 - Identification and Emergency Information, LIC 602A - Physician's Report, LIC 627C - Consent For Emergency Medical Treatment, LIC 625 - Appraisal Needs and Services Plan, and LIC 603A - Resident Appraisal. The investigation revealed the following: Regarding the allegation “Staff are not addressing resident’s medical needs.”
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
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 2
Control Number 11-AS-20230627083750
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: 06/30/2023
NARRATIVE
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It’s being alleged the facility has not provided residents with medical needs.

8 out of 8 residents interviewed disagreed with the allegation and denied having any issues obtaining medical needs from the facility.

4 out of 4 staff denied the allegation, S1, S2, S3, and S4 denied receiving any request for resident needing help with medical support or visit with doctors: Regarding the allegation “Staff are not addressing resident’s medical needs.”

Based on interviews conducted, record reviews and observation, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted with Jesse Loera-Mota, Administrator, and a copy of this report was provided.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2