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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 06/29/2021
Date Signed: 06/29/2021 05:13:52 PM

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: 90DATE:
06/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Yvette Lem, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a Case Management – Other visit. LPA was met by Yvette Lem, Administrator and the purpose of today’s visit was explained.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations.



LPA and staff toured the physical plant. During the tour LPA did not observe a complaint poster prominently posted in an area accessible to residents, representative and the public.

LPA requested for staff S1's staff record but administrator was not able to provide a copy for review.

Deficiencies were observed Title 22 regulations are being cited please see LIC809-D.

A exit interview was conducted and a hard copy of this and appeal rights was provided to Yvette Lem.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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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: 06/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/13/2021
Section Cited

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87468 Personal Rights(c) Licensees shall prominently post...complaint information in areas accessible to residents, representatives, and the public.(A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) ...entryway of the facility. This requirement was not met as evidenced by:
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Based on LPA observation the licensee failed to ensure that the complaint poster was poseted, During todays visit LPA did not observe the complaint poster posted, which poses a potential risk to the health and safety of clients in care.
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Type B
07/13/2021
Section Cited

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87412 Personnel Records (g)All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.

This requirement was not met as evidenced by:
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Based on LPA observation and interviews conducted the licensee failed to ensure that all personnel records are maintained at the facility and are available to the licensing agency for review. During todays visit the administrator was not able to provide staff S1's personnel record which poses a potential health and safety risk to clients 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: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2021
LIC809 (FAS) - (06/04)
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