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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 07/09/2024
Date Signed: 07/09/2024 04:36:53 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, 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
05/07/2024 and conducted by Evaluator Socorro Leandro
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240507115254
FACILITY NAME:VISTA VERANDA ASSISTED LIVINGFACILITY NUMBER:
197608044
ADMINISTRATOR:JESSE LOERA-MOTAFACILITY TYPE:
740
ADDRESS:3540 MARTIN LUTHER KING, JR.TELEPHONE:
(310) 638-4113
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:0CENSUS: 0DATE:
07/09/2024
UNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:LicenseeTIME COMPLETED:
04:06 PM
ALLEGATION(S):
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Facility staff did not dispense medications as prescribed
Facility staff dispensed medications without training
Facility staff did not assist diabetic resident as required
INVESTIGATION FINDINGS:
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On 06/19/2024, Licensing Program Analyst (LPA) Leandro delivered findings for the allegations listed above via mail due to facility closure.

The investigation consisted of the following:

On 05/15/2024, LPA conducted a tour of the facility, interviewed 5 out of 48 staff, and requested facility records.
On 5/16/2024, LPA requested resident records and facility timesheets for the month of May 2024. LPA interviewed 1 out of 48 staff, and 3 out of 60 residents (only 3 residents in the facility are diabetic who receive blood sugar checks).
A total of 6 out of 48 staff were interviewed and 3 out of 60 residents were interviewed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
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 5
Control Number 11-AS-20240507115254
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: 07/09/2024
NARRATIVE
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The investigation revealed the following:

Regarding the allegation “Facility staff did not dispense medications as prescribed,” it is being alleged that a medical technician (Staff 1) is combining dinner medications with bedtime medications. 3 out 3 residents indicated that bedtime medications were being provided around dinner time. 5 out 6 staff interviews indicated that night medications were not being provided and/or a medical technician (Staff 1) was providing night medications before they left which was around 5:00 PM to 6:00 PM. Record review of Personnel Report indicates that the facility does not have a Medical Technician 24/7. Moreover, there is no Medical Technician scheduled for Fridays from 5:31 PM to 12:00 AM and Saturdays from 2:30 PM to 12:00 AM. Record review of Medication Administration Records indicate that there are residents who have prescribed medication at 9:00 PM every day. Record review of Employee Timecards from 05/01/2024 to 05/15/2024 indicate that the last Medical Technician of the day left at 5:30 PM on 05/03/2024; 6:00 PM on 05/06/2024; 5:41 PM on 5/07/2024; 5:31 PM on 05/13/2024. Regarding the allegation “Facility staff did not dispense medications as prescribed,” the preponderance of the evidence standard has been met therefore the allegation is substantiated.

Regarding the allegation “Facility staff dispensed medications without training,” it is being alleged that Staff 2 who is has not received Medication Administration training provided evening medications to residents in care. 2 out of 6 staff indicated that a staff member who has not had training in Medication Administration provided evening medications to residents. Record Review of Employee Timecards on 05/02/2024 indicates that the last Medical Technician of the day left the facility at 2:12 PM. Regarding the allegation “Facility staff dispensed medications without training,” the preponderance of the evidence standard has been met therefore the allegation is substantiated.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20240507115254
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: 07/09/2024
NARRATIVE
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The investigation revealed the following: Regarding the allegation “Facility staff did not assist diabetic resident as required” it is being alleged that medical technicians are not assisting and recording diabetic residents’ blood sugars in the evening. 2 out 3 diabetic residents (the facility has 3 diabetic residents) indicated that they missed their evening blood sugar checks because the Medical Technician was not there. 5 out 6 staff interviews indicated that evening blood sugar checks were not being checked. Record Review of Blood Sugar Checks from 01/01/2024 to 05/15/2024 for two diabetic residents who receive their blood sugar check in the morning and in the evening indicated that both have several missing blood sugar checks for the month of May 2024. Regarding the allegation “Facility staff did not assist diabetic resident as required” the preponderance of the evidence standard has been met therefore the allegation is substantiated.

Deficiencies cited based on LPA record review and interviews conducted in accordance with the California Code of Regulations, Title 22. A copy of appeal rights and this report was emailed and mailed to Licensee for their records.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20240507115254
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2024
Section Cited
CCR
87411(a)
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Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs

This requirement was not met as evidence by:
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This deficiency is being cited for the record. No plans of correction required.
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Based on interviews conducted and record review, medical technician (Staff 1) did not dispense medication as prescribed, which poses a potential health risk to residents in care.
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Type B
07/09/2024
Section Cited
CCR
87413(a)(1)
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Personnel - Operations (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not met as evidence by:
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This deficiency is being cited for the record. No plans of correction required.
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Based on interviews conducted and record review, facility Staff 2 indicated that they passed out medication without Medication Administration training, which poses a potential health risk to residents 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) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20240507115254
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2024
Section Cited
CCR
87465(j)
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Incidental Medical and Dental Care (j) In all facilities…employees shall be…assisting residents...with self-administration of medications. The names of the staff employees…shall be…made known to all residents and staff. This requirement was not met as evidence by:
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This deficiency is being cited for the record. No plans of correction required.
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Based on interviews conducted and record review, medical technicians did not assist diabetic residents with their blood sugar checks as required.
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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) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5