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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 06/30/2023
Date Signed: 06/30/2023 01:29:48 PM


Document Has Been Signed on 06/30/2023 01:29 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
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: 60DATE:
06/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Jesse Loera-Mota, Administrator TIME COMPLETED:
01:35 PM
NARRATIVE
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On 06/30/2023, at 8:05 AM Licensing Program Analyst (LPA) David España met with Jesse Loera-Mota, Administrator during complaint visit. The purpose of this visit was to document deficiencies observed during investigation of a complaint with complaint control number 11-AS-20230627083750.

On 06/30/2023, LPA España and observed the A/C unit of an uncomfortable temperature in bedrooms 14, 15, 17, 16, 20, 22, 23, 32, 37, 173, 185, and 1st floor entrance hallway at the facility to clients in care. LPA observed uncomfortable temperature not meeting minimum requirements per 87303 Maintenance and Operation.

The licensee’s failure to correct violation may result in the violation of title 22 regulation. California Code of Regulations (Title 22, Division 6, Chapter 8), as this is a deficiency that was observed. (ref. LIC809-D).

An exit interview was conducted, plans of correction were developed and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
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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Document Has Been Signed on 06/30/2023 01:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2023
Section Cited
CCR
87303(b)(1)(2)(3)

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(b) A comfortable temperature for… (1) The facility shall heat rooms…(2) The facility shall cool rooms to a comfortable range, between 78…in areas of extreme heat to 30 degrees F… (3) Nothing in this section shall prohibit residents from adjusting…
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Licensee will install and/or fix A/C in bedrooms 14, 15, 17, 16, 20, 22, 23, 32, 37, 173, 185, and 1st floor entrance hallway and conduct staff training to ensure future compliance to 87303 (b)(1)(2)(3), no later than POC due date and provide licensing with proof via fax or email david.espana@dss.ca.gov.
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This requirement was not as evidence by: Based on observation, LPA and staff observed the A/C unit and uncomfortable temperature in in bedrooms 14, 15, 17, 16, 20, 22, 23, 32, 37, 173, 185, and 1st floor entrance hallway at the facility to clients in care. This presents a health and safety risk to client 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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
LIC809 (FAS) - (06/04)
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