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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 03/03/2022
Date Signed: 03/03/2022 03:29:29 PM


Document Has Been Signed on 03/03/2022 03:29 PM - It Cannot Be Edited

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:NISHITH MODIFACILITY TYPE:
740
ADDRESS:3540 MARTIN LUTHER KING, JR.TELEPHONE:
(310) 638-4113
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:178CENSUS: 72DATE:
03/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Nishith ModiTIME COMPLETED:
04:00 PM
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On 0303/2022 Licensing Program Analyst (LPA) Ulysses Coronel conducted a Case Management - Other visit and met with Nishith Modi, the administrator and the purpose of the visit was explained.

During todays visit LPA observed that the facility's is conducting symptom screenings and records the visitors contact information at the entrance. LPA and administrator conducted a tour of the facility and observed that the facility clean and sanitary and in good repair at time of visit. The administrator stated that caregiver staff Jennifer Mondaca resigned on 02/07/2022 and is in the process of hiring a new caregiver.

An exit interview was conducted a copy of this report was provided to the administrator.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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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