197608044-2-27-2021-11-AS-JHAD-BYX2RW-20210308163814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608044
Report Date: 02/19/2021
Date Signed: 02/27/2021 10:03:03 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
10/20/2020 and conducted by Evaluator Ulysses Coronel

COMPLAINT CONTROL NUMBER: 11-AS-20201020093821

FACILITY NAME:	VISTA VERANDA ASSISTED LIVING		FACILITY NUMBER:	197608044
ADMINISTRATOR:	MARCELLA CALVILLO		FACILITY TYPE:	740
ADDRESS:	3540 MARTIN LUTHER KING, JR.		TELEPHONE:	(310) 638-4113
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY:	178	CENSUS:	DATE:	02/19/2021
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Kinal Modi		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Resident sustained a fall resulting in death

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 10/20/2020 LPA conducted telephonic interviews with the administrator and 3 staff and reviewed food supply, physical plant, kitchen and resident bedrooms via video call. LPA requested copies of facility and staff records. On 10/21/2020 LPA interviewed staff S1. On 10/23/2020 LPA reviewed R1's resident records. On 01/29/2021 LPA reviewed facility and staff records. On 02/08/2021 LPA interviewed staff S3. On 02/09/2021 LPA reviewed staff records. On 02/16/2021 LPA interviewed satff S2. On 02/16/2021 LPA reviewed R1’s Death Certificate.

Unsubstantiated

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-20201020093821

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 10/20/2020 Administrator Nishith Modi stated that on 10/18/2020 around 11:00 pm resident R1 was observed in the bath tub by caregivers S1 and S2 and med tech S3. The paramedics came and declared R1's death". On 10/23/2020 staff S1 stated that on 10/18/2020 resident R2 went and told staff's S1 and S2 that there was a man in the bath tub, S1 and S2 immidiately went to look and saw R1 in the bath tub face down, S1 then reported the incident to med tech S3 who called 911 and conducted CPR. On 10/23/2020 record reviews, R1's Physician's Report indicate that "R1's Secondary Diagnoses are Hypertension and Hyperlipidemia. LPA also observed the following comments indicating that R1's Chronic neurocognitive impairment resulted from R1's history of severe polysubstance abuse and cardiovascular accident more than 10 years ago." On 02/08/2021 staff S3 stated that "I was on duty the day of the incident, I saw R1 face down in the bath tub, I immediately called 911 from my personal cellphone I spoke to the dispatcher they told me that they would send police and paramedics and they told me to start CPR and I did, the Firefighters arrived first they got there within a couple of minutes, and then they took over doing CPR after about 5 to 10 minutes they came out and informed me that R1 has past away. On 02/09/2021 record reviews indicate hat S3 has a valid First Aid Certificate. On 02/16/2021 staff S2 stated that "I checked for his pulse. I checked his chest for a heartbeat and to see if he was breathing, there were none." On 02/16/2021 record review of R1’s Death Certificate indicates that the Primary Cause of R1's Death was “Acute Cardiac Arrest”. We have found the complaint allegation “Resident sustained a fall resulting in death” as 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 was 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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