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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 12/07/2023
Date Signed: 12/07/2023 04:36:22 PM


Document Has Been Signed on 12/07/2023 04:36 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: 54DATE:
12/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:49 PM
MET WITH:Administrator, Jesse Loera-Mota. TIME COMPLETED:
05:00 PM
NARRATIVE
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On 12/07/2023 at 8:12 am 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 12/07/2023 at 9:30 am LPA España conducted a tour of facility plant S#1 and S#2; conducted interviews with Six (6) out of Fifty-Five (54) residents in care.

During the visit, LPA toured the facility which includes the kitchen area, office located in the kitchen, dining room area, and walked down the facilities hallways observed lights on the first floors (1) and second floor (2). LPA observed two (2) ceiling lights in memory care unit dining room not working. LPA observed the memory care unit hallways having two (2) ceiling lights not working.

LPA observed 15 ceiling lights in the RCFE side of the facility not working on the first floor. LPA observed ceiling lights by kitchen entrance back door cracked. LPA observed 16 ceiling light not working on the second floor of the RCFE side of the facility.

LPA observed all-roof top industrial A/C units, of which one (1) was out of order (no working). The administrator indicated he was not aware that one (1) of the industrial A/C units was not working. LPA observed one (1) industrial A/C unit with gas smells—which the facility called the gas company who arrived at the time of visit (i.e., 12:10 pm).

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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 12/07/2023 04:36 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: 12/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
87307(d)(1-7)

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87307(d)(1-7) relating to safety of resident accommodations:(d)The following space and safety provisions shall apply to all facilities: (1)Sufficient room shall... accommodate persons served in comfort and safety. (2)The premises shall be maintained in a state of good repair ...safe and...passageways and stairways shall be kept free of obstruction. (7)Fireplaces and open-faced heaters shall be adequately screened.
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The administrator agreed to review Title 22 Regulation 87307(d)(1-7) relating to safety of resident accommodations and signed that he understands safe and healthful environment of clients. Proof of correction to be submitted by POC due date david.espana@dss.ca.gov.
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Based on LPA observations and interviews conducted the licensee failed to ensure safe and healthful environment of clients 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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
LIC809 (FAS) - (06/04)
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