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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 12/01/2021
Date Signed: 12/03/2021 08:43:59 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
197608044
ADMINISTRATOR:YVETTE LEMFACILITY TYPE:
740
ADDRESS:3540 MARTIN LUTHER KING, JR.TELEPHONE:
(310) 638-4113
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:178CENSUS: 79DATE:
12/01/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:NIshith ModiTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel initiated an Office visit to document deficiencies observed during investigation of 2 complaints with complaint control number 11-AS-20210707110532 and 11-AS-20211012112144. Today’s visit was conducted telephonically with Licensee Representative Kinal Modi and Administrator Nishith Modi.

On 10/11/2021 staff LVN1, S1 and S8 failed to seek professional help for R1 who was observed wincing and complaining of pain between 5:30pm and 1:00am after an unwitnessed fall which resulted in injury and hospitalization.

On 11/18/2021 Trust Audit revealed that the LIC405’s used for residents P&I ledgers did not have a facility staff signature when money was withdrawn. The facility failed to provide the auditor documentations of periodic reconciliations of bank record, resident financial ledger and LIC 405s.

The deficiencies noted above indicate that the licensee failed to ensure that Administrator qualification requirements were met.

The deficiencies noted above indicate the that licensee has failed to exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with the regulations and the welfare of the residents it serves.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC809D.. An exit interview was conducted and hard copy was provided to administrator Nishith Modi.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2022
Section Cited

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87411(d)(5) Personnel Requirements – General. All personnel shall ... the job assigned to them. This... as appropriate for the job assigned and as evidenced by safe and effective job performance: Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement was not met as evidenced by:
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Based on record reviews and interviews conducted licensee failed to ensure that staff recognizes the need for professional help. LVN1, S1 and S8 failed to recognize the need for professional help after an unwitnessed fall that resulted to injury and hospitalization. This poses an immediate risk to the health and safety of residents in care.
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Type B
01/03/2022
Section Cited

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87217(g)(1)(A) Safeguards for Resident Cash, Personal Property, and Valuables. Each licensee shall maintain ... accurate records... following: Records...order. Each accounting shall be kept current. An...full signature... received. An...include: "(full signature of resident) ... from (payor)". This requirement was not met as evidenced by:
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Based on record reviews the licensee failed to maintain safeguards and accurate records of cash resources, the administrator failed to provide accurate records of cash resources and staff did not sign the residents P&I ledgers when money was withdrawn which poses a potential risk to the health and safety of 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2022
Section Cited

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87405(d)(1-3) Administrator - Qualifications and Duties. The administrator shall ..(7). If ... apply. Knowledge of...care and supervision appropriate to the residents. Knowledge of...laws, rules and regulations. Ability to maintain... records. This requirement was not met as evidenced by:
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Based on record reviews the licensee failed to ensure that the administrator has the knowledge of and ability to conform to the applicable laws, rules and regulations. And the ability to maintain of financial records, resulting to multiple deficiencies cited, which poses a potential health and safety risk to residents in care.
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Type B
01/03/2022
Section Cited

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87205(a) Accountability of Licensee Governing Body. The licensee,...individual or other entity, shall ... supervision over the affairs of the ...facility and establish policies ... in conformance with these regulations and the welfare of the individuals it serves. This requirement was not met as evidenced by:
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Based on record reviews the licensee failed to exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation resulting to multiple deficiencies cited, which poses a potential health and safety 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021
LIC809 (FAS) - (06/04)
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