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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 04/04/2024
Date Signed: 04/04/2024 03:17:17 PM


Document Has Been Signed on 04/04/2024 03:17 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: 56DATE:
04/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Administrator Eleanor BarrientosTIME COMPLETED:
03:25 PM
NARRATIVE
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On 04/04/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unaccounced visit to conduct a case management visit and met with Administrator Eleanor Barrientos.

During record review, LPA observed Resident #1's medical order form dated 02/27/2024 being unfulfilled. Interviews indicated that the medical order is still pending as of 04/04/24. Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and Plans of Corrections were developed and reviewed. A copy of this report and appeal rights were discussed and left with Administrator Eleanor Barrientos.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
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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Document Has Been Signed on 04/04/2024 03:17 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: VISTA VERANDA ASSISTED LIVING
FACILITY NUMBER: 197608044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2024
Section Cited
CCR
87465(a)(1)

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(a) A plan for... dental care shall be developed by each facility. The plan shall encourage routine... dental care and provide for assistance in obtaining such care... (1)The licensee shall arrange, or assist in arranging... dental care appropriate to the conditions and needs of residents.
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The Administrator will send verification that a dental appointment has been scheduled to regina.cloyd@dss.ca.gov by the POC date.
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This requirement was not met as evidenced by: LPA observed R1's unfulfilled dental medical document for "tooth extraction on ER basis" dated 02/27/24. On a scale of 1-10, R1 stated that R1's pain level is at a 9, which poses a immediate health risk to persons 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) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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