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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 04/19/2024
Date Signed: 04/19/2024 01:33:51 PM


Document Has Been Signed on 04/19/2024 01:33 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: 61DATE:
04/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Caregiver Supervisor - Patricia GarciaTIME COMPLETED:
01:45 PM
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On 04/19/2024 at around 12:40 PM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Case Management Visit to the above-named facility and met with the Caregiver Supervisor Patricia Garcia and the purpose of the visit was explained.

During today’s visit LPA conducted a tour of the facility, reviewed and obtained facility records which includes Personnel Report (LIC500) and Resident Census.

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

An exit interview was conducted, and a copy of this report was provided to the Caregiver Supervisor.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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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