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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 12/16/2022
Date Signed: 12/16/2022 05:12:42 PM


Document Has Been Signed on 12/16/2022 05:12 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
EL SEGUNDO, 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: 66DATE:
12/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Nishith ModiTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA called Administrator before entering the building. LPA met with Nishith Modi, Administrator. and the purpose of today’s visit was explained. The facility is licensed to serve residents age range 60 and over.

There are currently 66 residents. Licensed to serve 118 Non-Ambulatory & 60 Ambulatory residence. 2nd floor is cleared for 48 Non-Ambulatory residents’ rooms 183-168. Delayed Egress for Dementia units. Hospice Waiver Approved for 10 residents. The facility is a two-story building. It consists of the following: memory care unit, public bathrooms, reception area, front lobby, TV room, a storage room, activity office, employe lounge medication station, laundry room (personal and Linen), shower room, food/emergency supply room, maintenance supervisor office, dining area, kitchen and an elevator. On the second floor, the facility has bedrooms including memory care unit, library, business office, linen closet, dining room and janitor supply room. There is a large covered patio area. The passageway and walkaways are free from obstructions. The front, back and side areas of free of hazards. LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperatures measured 105.1F-111 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguishers was charged, smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

Exit interview was conducted and a copy of the report was given to Mr. Modi

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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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