079201430-3-19-2026-15-AS-LHAL-DSC2H9-20260319172423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201430
Report Date: 03/19/2026
Date Signed: 03/19/2026 05:24:48 PM

Document Has Been Signed on 03/19/2026 05:24 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	VISTA HOUSE		FACILITY NUMBER:	079201430
ADMINISTRATOR/ DIRECTOR:	SURNEY, WHITNEY		FACILITY TYPE:	735
ADDRESS:	1470 AUTUMN WIND CT		TELEPHONE:	(925) 214-7081
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94565
CAPACITY: 6		CENSUS: 5	DATE:	03/19/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:30 PM
MET WITH:	Nickolas Walker, Direct Care Support		TIME VISIT/ INSPECTION COMPLETED:	05:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/19/2026 at 2:30pm, Licensing Program Analysts (LPAs) L. Hall and C. Fowler conducted an unannounced annual required inspection. LPA met with Nickolas Walker, Direct Support Staff. Administrator Whitney Surney, arrived at 2:50pm, and LPAs explained the purpose of the visit. The administrator currently holds a certificate (#6074315735) that expires on 01/09/2027. The facility’s fire clearance was approved for six (6) ambulatory clients. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of seven (7) bedrooms and three (3) full bathrooms and two (2) 1/2 bathrooms. Two (2) bedrooms occupied by staff. All indoor and outdoor passageways are kept free of obstruction. LPA observed swimming pool gated and locked. A comfortable temperature for clients is maintained at 78 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 108.2 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods. Continued on LIC809C.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VISTA HOUSE	FACILITY NUMBER: 079201430
	VISIT DATE: 03/19/2026

NARRATIVE

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Continued from LIC809.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/26/2024. First aid kit was observed to be complete.

LPA reviewed three (3) of five (5) staff files and five (5) client files. LPA reviewed a sample of clients' medication.

The following forms to be updated and submitted to CCLD by 3/26/2026:

LIC610D Emergency disaster plan (last page)
Surety Bond
LIC308 (Designation of facility Responsibility)
LIC400 (Affidavit Regarding Client/Resident Cash Resources)
LIC500 (Personnel Report)
A copy of the Administrator certificate.

LPAs observed the following deficiencies:

At 2:45pm, LPAs observed padlock on kitchen cabinet underneath kitchen sink was unlocked. Raid and Awesome disinfectant was in cabinet.
At 3:30pm, LPAs observed during record review there were only three (3) out of five (5) client records to be reviewed.

Continued on LIC809C.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VISTA HOUSE	FACILITY NUMBER: 079201430
	VISIT DATE: 03/19/2026

NARRATIVE

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Continued from LIC809C.

At 3:30pm, LPAs observed during record review clients P & I was not available for review.
LPA observed facility do not have a landline telephone.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/19/2026 05:24 PM - It Cannot Be Edited

Created By: Laura Hall On 03/19/2026 at 05:00 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VISTA HOUSE	FACILITY NUMBER: 079201430
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having disinfectants accessible underneath kitchen cabinet which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/20/2026
	Plan of Correction
1 2 3 4	Administrator locked cabinet with padlock. Deficiency cleared during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:

	Laura Hall
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/19/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/19/2026 05:24 PM - It Cannot Be Edited

Created By: Laura Hall On 03/19/2026 at 05:00 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VISTA HOUSE	FACILITY NUMBER: 079201430
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80073(a)

Telephones

(a) All facilities shall have telephone service on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not having a land line phone number for facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/26/2026
	Plan of Correction
1 2 3 4	Administrator agreed to obtain a working land line phone and submit number to CCLD by POC date.

Type B

Section Cited

CCR

80070(a)

Client Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in having two (2) of the resident files available for review which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/26/2026
	Plan of Correction
1 2 3 4	Administrator agreed to submit self-certification that all files will be kept at facility and readily available to review.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:

	Laura Hall
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/19/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 03/19/2026 05:24 PM - It Cannot Be Edited

Created By: Laura Hall On 03/19/2026 at 05:00 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VISTA HOUSE	FACILITY NUMBER: 079201430
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80070(b)(14)

Client Records

(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in having clients cash resources available for review which poses a poses a personal rights risk to persons in care.
	POC Due Date: 03/26/2026
	Plan of Correction
1 2 3 4	Administrator agreed to submit copies of each client's cash safeguard document to CCLD by POC date.

Type B

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in conducting a quarterly fire drill which poses a potential health or safety risk to persons in care.
	POC Due Date: 03/26/2026
	Plan of Correction
1 2 3 4	Administrator agreed to conduct a fire drill and submit documentation to CCLD by POC 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.

	Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:

	Laura Hall
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/19/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

LIC809 (FAS) - (06/04)

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