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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320361
Report Date: 04/19/2024
Date Signed: 04/19/2024 03:18:07 PM


Document Has Been Signed on 04/19/2024 03:18 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:SUNRISE VISTA ASSISTED LIVING,LLCFACILITY NUMBER:
198320361
ADMINISTRATOR:HAUF, MARYFACILITY TYPE:
740
ADDRESS:3342 ARTESIA BLVDTELEPHONE:
(657) 215-5615
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY:6CENSUS: 6DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Josephine HaufTIME COMPLETED:
03:30 PM
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On 04/19/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Administrator, Josephine Hauf, and the purpose of today’s visit was explained. The facility is licensed for 6 non-ambulatory residents aged 60 and over with a hospice waiver of four (4). There are currently six (6) residents residing in the facility and all residents were present during today’s visit.
Physical Plant/Structure The facility is a single-story home in a residential neighborhood. The home consists of four (4) resident bedrooms, staff room, three (3) bathrooms, living room, sitting room, kitchen, laundry room, detached garage, front and back yard. LPA observed a shaded patio with table and chairs. There is a jacuzzi on the patio that has a locked cover and is inaccessible to residents. LPA observed all walkways to be clean, clear, and free of debris, hazards, and obstructions. All fences open easily from the inside to exit.
Bedrooms LPA inspected all bedrooms in the facility and observed them to be clean and in good repair. LPA observed all rooms have the required furniture including a bed, dresser, nightstand, chair, storage space for resident’s personal belongings, and ample lighting. LPA observed resident beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of bed linens in a cupboard in the hall and an additional supply in the closet of bedroom 5.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (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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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: SUNRISE VISTA ASSISTED LIVING,LLC
FACILITY NUMBER: 198320361
VISIT DATE: 04/19/2024
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Bathrooms LPA inspected all bathrooms and observed them to be clean and operational. The showers were free of mildew and mold. All showers had a nonskid mat, shower chair, and secured safety handrails. LPA observed and ample supply of hygiene products in a cupboard in the front sitting room. Additionally, LPA observed an ample supply of towels, hand towels and wash clothes in the cupboard in the hallway. Cleaning supplies are secured in a locked cabinet under the sink and are inaccessible to residents. The water temperature measured 109.4-degrees to 110.7-degrees Fahrenheit.
Kitchen LPA inspected the kitchen and found it to be clean and sanitary. LPA observed all appliance to be operational and in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods properly labeled, dated, and packaged. The water temperature measured 109.8-degree Fahrenheit. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed knives and sharps to be secured in a locked cabinet in the kitchen and are inaccessible to residents. LPA observed cleaning supplies to be secured in a locked closet in the laundry room and are inaccessible to residents.
Common Rooms In the living room LPA observed a couch and chairs to accommodate all residents. LPA observed a fireplace that is screened and inaccessible to residents. In the sitting room LPA observed chairs available for residents. The dining room has a large rectangular table and six (6) chairs to accommodate all residents. All walkways were observed to be clean, clear, and free of obstructions and hazards. LPA observed ample lighting in all walkways and hallways.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (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
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: SUNRISE VISTA ASSISTED LIVING,LLC
FACILITY NUMBER: 198320361
VISIT DATE: 04/19/2024
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Medications LPA observed all Centrally Stored Medications were secured in a locked cabinet in dining room and are inaccessible to residents. All medications were observed in their original containers. LPA reviewed the Centrally Stored Medications for five (5) residents and the Medication Administration Record (MAR) and found they are consistent with properly documented records.
Safety LPA observed and reviewed the facility Disaster Plan and Emergency numbers posted in the facility. LPA observed smoke detectors to be operational. LPA observed a carbon monoxide detector in the living room to be operational. LPA observed a facility sketch posted in the sitting room. LPA observed two (2) fully charged fire extinguishers, one mounted in the kitchen and the other in the living room, purchased on 04/09/24. The last emergency drill was conducted on 04/15/24. LPA inspected the First Aid Kit and observed it had the required items and a manual. There are no firearms or ammunition on the premises.
Files/Interviews LPA reviewed the files for six (6) residents and found they contained the required documentation. LPA interviewed four (4) residents who were happy with the care, and services provided by the facility. LPA reviewed the administrator and three (3) staff files and found they contained the required documents, certification, and training. LPA interviewed two (2) caregivers who were able to answer questions regarding resident care, policy, procedure, and resident rights. LPA received and reviewed a copy of the Liability Insurance through Primary Care Insurance which is valid till 08/21/24. During file review, LPA observed the facility is up to date on all licensing fees. LPA observed all required documents posted within the facility.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (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
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: SUNRISE VISTA ASSISTED LIVING,LLC
FACILITY NUMBER: 198320361
VISIT DATE: 04/19/2024
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Infection Control LPA observed the facilities Infection Control practices. At the entrance of the facility is a sanitizing station. LPA observed a Visitor Log with screening and temperature log. LPA observed hand sanitizer and masks. LPA observed caregivers wearing face masks. LPA observed a 90-day supply of Personal Protective Equipment (PPE) in the closet in the sitting room.

During today's visit, LPA did not observe or cite any deficiencies.

And exit interview was conducted with Administrator, Josephine Hauf, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (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
LIC809 (FAS) - (06/04)
Page: 2 of 4