197608044-4-19-2024-11-AS-UCOL-D4MVWG-20240424164754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 04/04/2024
Date Signed: 04/19/2024 11:04:20 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
03/26/2024 and conducted by Evaluator Regina Cloyd

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240326115436

FACILITY NAME:	VISTA VERANDA ASSISTED LIVING		FACILITY NUMBER:	197608044
ADMINISTRATOR:	JESSE LOERA-MOTA		FACILITY TYPE:	740
ADDRESS:	3540 MARTIN LUTHER KING, JR.		TELEPHONE:	(310) 638-4113
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY:	178	CENSUS: 56	DATE:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Eleanor Barrientos		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff did not ensure resident's records were properly maintained

INVESTIGATION FINDINGS:

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The purpose of the amendment is to provide additional information and it does not change the investigation findings. On 04/04/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Administrator Eleanor Barrientos and explained the purpose of the visit.

The investigation consisted of the following: During today’s investigation, LPA reviewed (10) resident records, interviewed 1 resident and 5 staff members which included the Caregiver Supervisor, (2) MedTech, Receptionist and Caregiver.

Continue to LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

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-20240326115436

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/04/2024

NARRATIVE

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Allegation(s):

Staff did not ensure resident's records were properly maintained.

The investigation revealed the following: Regarding the allegation "Staff did not ensure resident's records were properly maintained,” it is being alleged that staff misplaced resident’s (R1’s) dental records. Interviews conducted indicate the following: Interviews with MedTech (S1 and S3) indicated that dental services are provided both on site and off site. Once services are delivered on site, the third party vendor leaves or fax records to MedTechs for residents’ files. Record review indicates that R1’s dental documentation are filed. Based on the interviews and record reviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted and a copy of this report was provided to Receptionist Saul Nieto.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

LIC9099 (FAS) - (06/04)

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