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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 03/06/2024
Date Signed: 03/06/2024 02:48:38 PM


Document Has Been Signed on 03/06/2024 02:48 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 ASC, 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: 58DATE:
03/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Administrator Jesse Loera-Mota TIME COMPLETED:
03:00 PM
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On 03/06/2024 at around 1:10 PM, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Case Management Visit to the above-named facility and met with the Administrator Jesse Loera-Mota and the purpose of the visit was explained.

During todays visit LPM and LPA conducted a tour of the facility, reviewed and obtained facility records which includes Personnel Report (LIC500), Register of Facility Residents - Residential Care Facilities For The Elderly (LIC9020A), Food Purchase Order with delivery date of 03/07/2024, and documentation of Residents Cash Resources.

No deficiencies were cited based on LPM and LPA’s observation and record reviews in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted, and a copy of this report was emailed to Administrator due to technical difficulties.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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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