197608044-2-27-2021-11-AS-JHAD-BYX2JG-20210308162616

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 02/19/2021
Date Signed: 02/27/2021 10:57:50 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
11/09/2020 and conducted by Evaluator Ulysses Coronel

COMPLAINT CONTROL NUMBER: 11-AS-20201109080334

FACILITY NAME:	VISTA VERANDA ASSISTED LIVING		FACILITY NUMBER:	197608044
ADMINISTRATOR:	NISHITH MODI		FACILITY TYPE:	740
ADDRESS:	3540 MARTIN LUTHER KING, JR.		TELEPHONE:	(310) 638-4113
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY:	178	CENSUS: 105	DATE:	02/19/2021
		UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Kinal Modi		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility staff failled to meet reporting requirements.

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 11/16/2020 LPA Coronel conducted telephone interview with the administrator and video call which consisted of a review of the physical plant, kitchen and resident bedrooms. The LPA interviewed resident R1 and staffs S1 and S2. The LPA requested copies of resident R1's resident records including Emergency and Identification Information, Resident Appraisal (LIC603A) Admission Agreements, Needs and Services Plans (LIC625), most current Physician Reports (LIC602A), Hospital Discharge Paperwork’s, Case Notes/Logs, Medication Logs (MAR Jan-Oct 2020) and all Incident Reports (LIC624) since R1's admission. On 12/15/2020 LPA interviewed witness W1. On 02/02/2021 LPA requested R1’s resident records. On 02/07/2021 LPA reviewed R1’s records.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (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)

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Control Number 11-AS-20201109080334

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: On 10/21/2020 R1 was admitted to the VA hospital due to R1’s refusal for care and aggressive behavior towards staff. On 11/16/2020 LPA did not observe submission of incident reports to CCL by the facility regarding R1’s behavior outburst toward facility staff or of R1’s admission to the VA hospital on 10/21/2020. On 12/15/2020 W1 indicated that they did not receive notice of R1’s aggressive acts towards the caregivers or of R1’s hospitalization on 10/21/2020, W1 added that had they been contacted they might have been able to provide the facility information to help R1’s care and supervision. On 02/07/2021 LPA conducted another records review and did not observe any incident reports regarding R1’s aggressive acts towards staff nor R1’s hospitalization. On 02/11/2021 S1 stated that "We did not submit incident reports about residents getting agressive or striking out staff." Regarding the allegation: “Facility staff failed to meet reporting requirements.” 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, Tittle 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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (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)

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Control Number 11-AS-20201109080334

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 87211(a)(1)(D)	1 2 3 4 5 6 7	87211(a)(1)(D) Reporting Requirements Each licensee shall furnish to the licensing agency..., the following: A written report shall be submitted to the licensing agency and to the person responsible...of any of the events ... case.Any incident which threatens the welfare, safety or health of any ...resident.	1 2 3 4 5 6 7	The Licensee shall develop a plan outlining the steps to be taken to ensure proper submission of reports to the licensing agency and to the person responsible for the resident as outlined by Title 22 Regulations 87211 on all Reporting Requirements . Proof of correction shall be submitted by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on record reviewes and interviews conducted the Licensee failed to ensure that written reports were submitted to the licensing agency and R1's responsible person which poses a potential risk to the health and safety of residents 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: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (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)

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