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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 12/06/2023
Date Signed: 12/06/2023 04:57:11 PM


Document Has Been Signed on 12/06/2023 04:57 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:JESSE LOERA-MOTAFACILITY TYPE:
740
ADDRESS:3540 MARTIN LUTHER KING, JR.TELEPHONE:
(310) 638-4113
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:178CENSUS: 55DATE:
12/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jesse Loera-Mota, Administrator TIME COMPLETED:
05:00 PM
NARRATIVE
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On 12/06/2023 at 1:30 pm Licensing Program Analyst (LPA) David España conducted case management visit to issue deficiencies. Upon arriving at the facility, LPA met with S#1 who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections.

The investigation consisted of the following: On 12/06/2023 at 1:30 pm LPA España conducted a tour of facility plant S#1 and S#2; conducted interviews with Six (6) out of Fifty-Five (55) residents in care.

LPA confirmed that there are currently Fifty-Five (55) residents in care as of 12/06/2023. LPA confirmed that there is Forty-Five (45) Staff employed as of 12/06/2023/ LPA confirmed that was Seventeen (17) staff working at the time of visit. LPA observed if the smoke and carbon monoxide detectors were complying and operational with Title 22 regulations. LPA observed the following: All outdoor and indoor passageways are kept free of obstruction. The bathroom toilets and water faucets worked properly. Sufficient toiletries accessible to clients. Per regulation, the facility shall cool rooms to a comfortable range, between 78 degrees F and 85 degrees F, or in areas of extreme heat to 30 degrees F less than the outside temperature.

LPA observed the following Memory Care Units Rooms #15, #19, #20, #21, #27, #32, #31, #30, and #28. LPA conducted interviews with Six (6) out of Fifty-Five (55) residents in care. At 3:10 pm LPA España conducted a tour with S#1 in the Memory Care Unit. Based on LPA observations, all window blinds were not clean or maintained in good repair (i.e., Rooms #15, #19, #20, #21, #27, #32, #31, #30, and #28).

Based on information obtained the deficiencies discovered were issued on 809D



Exit interview held. 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: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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 2


Document Has Been Signed on 12/06/2023 04:57 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: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
87303(a-e)

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(a)The facility shall be clean, safe, sanitary and in good repair… employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. (b) A comfortable temperature for residents shall be.... (e)Water supplies and plumbing fixtures shall be maintained as follows…
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Administrator agreed to replace the broken window screen and broken blinds by the POC due date (Take picutes of window/exit door blinds and email to LPA by POC).
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The window/exit door blinds in Rooms #15, #19, #20, #21, #27, #32, #31, #30, and #28 are cracked, slats are missing and broken.
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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: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
LIC809 (FAS) - (06/04)
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