197608044-5-9-2024-11-AS-JHAD-D5CT9U-20240517143230

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 05/09/2024
Date Signed: 05/09/2024 01:16:56 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2024 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240503124957

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: 61	DATE:	05/09/2024
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Saul Nieto		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee does not ensure that the facility has an administrator.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 05/09/24, at 09:30am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Saul Nieto, Receptionist. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegation mentioned above.

The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R4). Resident Roster, Staff Roster, Personnel Report LIC 501, Criminal Background Clearance LIC 508, Transfer Request LIC 9182, Job Offer Document, CPR Certificate, and Emergency Disaster Plan LIC 610E were obtained from the facility. Files to be emailed to LPA are Designation of Facility responsibility LIC 308, Health Screening Report LIC 503, and Administrator Certificate for new hire.

The investigation revealed the following: Allegation #1- Licensee does not ensure that the facility has an administrator.

Report continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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-20240503124957

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VISTA VERANDA ASSISTED LIVING	FACILITY NUMBER: 197608044
	VISIT DATE: 05/09/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The details of the complaint alleged that the facility does not have a current administrator; and that the prior administrator resigned on 03/20/2024. On 05/09/24, from 9:30am-12:00pm, LPA interviewed staff (S1-S4) and residents (R1-R4) regarding the allegation. 4 of 4 staff (S1-S4) confirmed the allegation that the Licensee does not ensure that the facility has an administrator. All staff stated that there was not an administrator at the facility. S1 stated that S1 was an acting Administrator from 03/18/2024-04/12/2024. S2, Licensee Representative, stated that there is not a current administrator for the facility, however a new administrator is scheduled to start on 05/16/24.

LPA interviewed residents R1-R4 about the allegation that Licensee does not ensure that the facility has an administrator. 4 of 4 residents that were interviewed confirmed that there was not an administrator onsite for the facility. LPA observed that from 04/12/24 through 05/16/24 the facility will not have an active administrator onsite.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation: Licensee does not ensure that the facility has an administrator, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D.

Deficiencies are issued and plans of corrections were discussed.

An exit interview was conducted with Saul Nieto, Receptionist. A copy of this report and appeal rights were provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20240503124957

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VISTA VERANDA ASSISTED LIVING	FACILITY NUMBER: 197608044
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/16/2024 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator...The administrator shall have ... other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to submit an administrator packet of a certified and qualified designate as the primary administrator in place. Licensee will email an updated LIC 500, LIC 308, LIC 503, and Administrator Certificate by the POC due date 05/16/24 to LPA Perry Scott at perry.scott@dss.ca.gov
	8 9 10 11 12 13 14	Based on interviews and record reviews, the licensee failed to ensure that a qualified and currently certified administrator was onsite during the period of 04/12/24 - 05/16/24. This violation poses a potential health, safety, or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3