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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 02/19/2021
Date Signed: 02/27/2021 09:10:00 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/22/2020 and conducted by Evaluator Ulysses Coronel
COMPLAINT CONTROL NUMBER: 11-AS-20200922093832
FACILITY NAME:VISTA VERANDA ASSISTED LIVINGFACILITY NUMBER:
197608044
ADMINISTRATOR:MARCELLA CALVILLOFACILITY TYPE:
740
ADDRESS:3540 MARTIN LUTHER KING, JR.TELEPHONE:
(310) 638-4113
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:178CENSUS: DATE:
02/19/2021
UNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Kinal ModiTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility staff is not providing a safe environment due to repeated falls
Staff did not provide care and supervision necessary to meet residents needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Kinal Modi the Licensee Representative.

The investigation Consisted of the following:
On 09/29/2020 LPA conducted a review of food supply, physical plant, kitchen and resident bedrooms. The LPA also requested copies of R1, R2 and R3’ most current Physician Reports, Admission Agreements, Needs and Services Plans, Incident Reports, Hospital Discharge Paperwork’s (if applicable), Hospice Notes, Home Health Notes, Case Notes, Medication Logs and Emergency and Identification Information. On 11/02/2020 LPA conducted facility and resident record reviews. On 11/12/2020 LPA interviewed 10 out of 114 residents. On 12/14/2020 LPA conducted residents record reviews. On 02/02/2021 LPM Hammond and LPA interviewed the administrator and 4 staff, LPA requested resident records. On 02/04/2021 LPA interviewed 10 out of 105 residents. On 02/05/2021 LPA conducted record reviews.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
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 5
Control Number 11-AS-20200922093832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044
VISIT DATE: 02/19/2021
NARRATIVE
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The investigation revealed the following:

Regarding the allegation: “Facility staff is not providing a safe environment due to repeated falls”. On 02/05/2021 LPA did not observe documentation of R1’s Unusual Incident/Injury Reports, Annual Appraisal/Needs and Services Plan or of R1’s reassessments following R1’s hospitalization's on 06/22/2019 due to a fall resulting to injury, on 07/23/2020 due to increasing weakness and decrease food intake, on 07/29/2020 due to a fall resulting to injury and on 08/01/2020 due to falls resulting to lower back pain and abnormal gait due to impairment of weight loss, record reviews indicate that R1 lost around 50.1 pounds from March 2019 to July 2020. On 02/05/2021 Administrator indicated the following: “I did not see the Needs and Services Plans and Reappraisals in R1’s resident charts." And “I did not conduct Appraisal/Needs and Services Plans or reassess any residents since I stepped in.” Based on LPA’s observations, interviews and record reviews, the preponderance of evidence standard has been met therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 are being cited. Please see LIC 9099-D.

Regarding the allegation: “Staff did not provide care and supervision necessary to meet resident’s needs” On 02/05/2021 LPA did not observe documentation of R2’s Annual Appraisal/Needs and Services Plan or of R2’s reassessments, record reviews indicate that R2 lost 57 pounds from July 2019 to August 2020. On 02/05/2021 Administrator indicated the following: “I did not see the Needs and Services Plans and Reappraisals in R2’s resident charts." And “I did not conduct Appraisal/Needs and Services Plans or reassess any residents since I stepped in.” Based on LPA’s observations, interviews and record reviews, the preponderance of evidence standard has been met therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 are being cited. Please see LIC9099-D.

A hard copy of this report and licensee rights were explained and provided via email for signature.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20200922093832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2021
Section Cited
CCR
87705(c)(5)(A)
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87705(c)(5)(A)Care of Persons with Dementia Licensees...responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment... a reappraisal done at least annually... dementia care needs. When any...changes shall be made in the care and supervision provided to that resident.
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The Licensee shall develop a plan outlining the steps to be taken to ensure the requirements outlined by Title 22 Regulations 87705(c)(5)(A) Care of Persons with Dementia are met. Proof of correction shall be submitted by POC due date.
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This Requirement was not met as evidenced by: Based on record reviews and interviews conducted: the licensee failed to ensure that an annual medical assessment was made and changes were made to the care and supervision of R1 which poses potential a risk to clients in care.
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Type B
02/26/2021
Section Cited
CCR
87705(c)(6)
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87705(c)(6) Care of Persons with Dementia Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.
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The Licensee shall develop a plan outlining the steps to be taken to ensure the requirements outlined by Title 22 Regulations 87705(c)(6) Care of Persons with Dementia are met. Proof of correction shall be submitted by POC due date.
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This Requirement was not met as evidenced by: Based on record reviews and interviews conducted: the licensee failed to ensure that Appraisals are conducted on an ongoing basis for R1 and R2 which poses potential a risk to clients 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/22/2020 and conducted by Evaluator Ulysses Coronel
COMPLAINT CONTROL NUMBER: 11-AS-20200922093832

FACILITY NAME:VISTA VERANDA ASSISTED LIVINGFACILITY NUMBER:
197608044
ADMINISTRATOR:MARCELLA CALVILLOFACILITY TYPE:
740
ADDRESS:3540 MARTIN LUTHER KING, JR.TELEPHONE:
(310) 638-4113
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:178CENSUS: DATE:
02/19/2021
UNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Kinal ModiTIME COMPLETED:
06:30 PM
ALLEGATION(S):
1
2
3
4
5
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7
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9
Staff are not answering the phone in a timely manor and residents are not getting calls.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Kinal Modi the Licensee Representative.

The investigation Consisted of the following:

On 09/29/2020 LPA conducted a review of food supply, physical plant, kitchen and resident bedrooms. The LPA also requested copies of R1, R2 and R3’ most current Physician Reports, Admission Agreements, Needs and Services Plans, Incident Reports, Hospital Discharge Paperwork’s (if applicable), Hospice Notes, Home Health Notes, Case Notes, Medication Logs and Emergency and Identification Information. On 11/02/2020 LPA conducted facility and resident record reviews. On 11/12/2020 LPA interviewed 10 out of 114 residents. On 12/14/2020 LPA conducted residents record reviews. On 02/02/2021 LPM Hammond and LPA interviewed the administrator and 4 staff, LPA requested resident records. On 02/04/2021 LPA interviewed 10 out of 105 residents. On 02/05/2021 LPA conducted record reviews.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20200922093832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044
VISIT DATE: 02/19/2021
NARRATIVE
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Regarding the allegation: “Staff are not answering the phone in a timely manner and residents are not getting calls.” On 02/05/2021 10 out of 10 residents stated that they did not have any problems making or taking phone calls. Resident R2 stated “No, I talk to my daughter every day. They call me and I go to the dining room, then we talk for hours.” On 02/05/2021 Staff S1 stated that “Sometimes when residents get calls and they are in the room, they don’t hear that we are buzzing them, If I am working and they don’t hear, I go to their room and knock on their door to tell them they have a call, but sometimes the residents are not there to take their calls so we tell them, they are not here. The med tech are supposed to answer calls first, then the activity staff and then the caregivers needs to answer it, there is always someone here to answer. We have found the complaint allegation unsubstantiated, although the allegation may have happened or is valid; there is not a preponderance of the evidence to prove that the alleged violation occurred.

A hard copy of this report was provided via email for signature.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5