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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608029
Report Date: 09/24/2025
Date Signed: 09/24/2025 03:47:06 PM

Document Has Been Signed on 09/24/2025 03:47 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR/
DIRECTOR:
SUZETTE S. JOHNSONFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 300CENSUS: 252DATE:
09/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:23 AM
MET WITH:Suzette JohnsonTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On 09/24/25 Licensing Program Analyst's (LPA's) Villegas and Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA's met with Executive Director Suzette Johnson as the purpose of today’s visit was explained. The facility is licensed to serve 300 non-ambulatory elderly adults 60 and over of which 10 may be bedridden, there is an approved hospice waiver for 50 residents. The facility has a dementia wing w/ delayed egress. Annual fees are current, the facility has an active liability insurance with expiration date of 10/26/25.

The facility is a 3-story structure located in a residential neighborhood and consists of the following: 278 bedrooms, 4 common bathrooms, multimedia rooms, commercial kitchen, activity room, large dining room, medication room, a large outside patio, laundry room, and administrative offices. There is an memory care unit is located on the 2nd floor of the facility which contains delayed egress doors that were observed to be operable, a common space, dinning/kitchen area, med room, administrative office, and laundry area.

LPA’s conducted a records review of 6 staff records, 10 resident records, and 10 medication administration records, records were maintained accordingly with no discrepancies. LPAs observed medications were centrally stored and properly locked. The last fire and disaster drill was conducted on 09/15/25 by the fire safety services inc., fire extinguishers fully charged and observed throughout the facility, carbon monoxide detectors, smoke detectors and auditory signals are operational. Fire/Smoke door inspection conducted on 06/05/25 by DC Electronics, inc. Evacuation chair observed on on each floor at the stairwell.

During facility tour 6 Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Lizeth Villegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 09/24/2025
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worked properly, showers were free of mold/mildew, and there are sufficient toiletries accessible to residents. Pull cords observed in every bathroom, Water temperatures were tested in the kitchen(s), and in 6 bedrooms. LPAs conducted tour of commercial kitchen, LPAs observed an adequate supply of perishable and non-perishable food. Toxins and knifes were observed to be inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards.

Exit interview conducted, appeal rights explained, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Lizeth Villegas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/24/2025 03:47 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 09/24/2025 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VISTA DEL MAR SENIOR LIVING

FACILITY NUMBER: 197608029

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 09/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department or
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Staff #7 is not associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2025
Plan of Correction
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Licensee/Executive Director will ensure that S7 is associated to the facility before being scheduled to work shift. LPA to obtain proof of S7's association to the facility by POC due date.
Request Denied
Type A
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation
Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) the licensee did not comply with the section cited above as water temperatures in bedrooms 119, 135, 137, 217, and ML22 were observed to not be within range of 105 F -120 F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2025
Plan of Correction
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Licensee/Executive Director to lower the water heater, and continue to check the water temparatures in bedrooms:
licensee will self certify water temperatres are within requred range of 105F-120F and submit proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
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