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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 095002887
Report Date: 02/15/2022
Date Signed: 02/15/2022 12:54:20 PM


Document Has Been Signed on 02/15/2022 12:54 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:VISTA HILLS SENIOR CARE INCFACILITY NUMBER:
095002887
ADMINISTRATOR:DHAMI, SONAMJEETFACILITY TYPE:
740
ADDRESS:1660 DOWNIEVILLE CTTELEPHONE:
(650) 740-1680
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 0DATE:
02/15/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sagar Singh & Sonamjeet DhamiTIME COMPLETED:
12:45 PM
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Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Singh, Sagar (Corporate Board Member) & Dhami, Sonamjeet (Administrator and Corporate Board Member) Interview Method: Telephone interview
On 2/15/2022, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Tracy ThompsonTELEPHONE: () -
LICENSING EVALUATOR NAME: Bailey HumesTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
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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