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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608044
Report Date: 11/30/2023
Date Signed: 11/30/2023 05:14:11 PM


Document Has Been Signed on 11/30/2023 05:14 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: 55DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:JESSE LOERA-MOTATIME COMPLETED:
05:25 PM
NARRATIVE
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On 11/30/2023 at around 10:00 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Administrator Jesse Loera-Mota. LPA explained the purpose of the visit and was accompanied by the Administrator inside and outside the facility during this inspection.

This facility has a capacity of 178 residents. The facility is licensed to serve 118 non-ambulatory adults and 60 ambulatory adults ages 66 and above. 2nd floor is cleared for 48 non-ambulatory adults. Facility is approved to serve residents with dementia and has a hospice waiver for 10 residents.

Annual Licensing Fees are due on 12/17/2023 with a balance of $2,311.

This is a two-story facility, which consists of: 88 resident bedrooms, 95 bathrooms, 1 industrial kitchen, 1 facility laundry room, 1 resident laundry room, 1 family room, 1 activity room, 1 library/computer room, 6 office rooms, 1 lobby, 2 dining rooms, 2 resident telephones, 1 employee lounge, 1 tv room, and 3 patios with outside seating.

Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises.

LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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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
VISIT DATE: 11/30/2023
NARRATIVE
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LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last fire drill was conducted on 9/18/2023. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. Fire Clearance was granted on 7/19/2023 by the County of Los Angeles Fire Department. The fire extinguisher was observed in the kitchen area and was last serviced on 10/24/2023. Facility is missing evacuation chair at each stairwell.

7 out of 7 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as toilet paper. LPA observed loose closet mirror door. LPA observed signal system not working properly in two resident bedrooms (staff members are able to hear the ring of the signal system but are unable to hear the resident voices).

5 staff records were reviewed, 5 out of 5 staff records had current First Aid Certificates, Criminal Record Clearances, Job Applications, Tuberculosis Test, Facility Trainings/Drills, and signed Employee Rights.

5 resident records were reviewed and, 5 out of 5 resident records had Admission Agreements, Medical Assessments, Consent Forms, Weight Record, Emergency Information, Appraisal & Needs Service Plan, Tuberculosis Test, Centrally Stored Medication Destruction Record, and Personal Rights.

Deficiencies are being cited based on LPA observations and interviews conducted and in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding missing evacuation chair at each stairwell and facility being in good repair.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 11/30/2023 05:14 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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview, the licensee did not comply with the section cited above in, loose mirror closet doors in room 33 and signal system not working properly (due to staff unable to hear residents throught the system), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Licensee will fix mirror closet doors in room 33 and facility's signal system. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.
Type B
Section Cited
HSC
1569.695(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not having an evacuation chair at each stairwell, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Licensee will place an evacuation chair at each stairwell and email proof of correction to Socorro.Leandro@dss.ca.gov.
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) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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