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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208866
Report Date: 12/06/2021
Date Signed: 12/06/2021 11:37:13 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:VISTA ELDERLY CARE FACILITYFACILITY NUMBER:
107208866
ADMINISTRATOR:ABALOS, CORAFACILITY TYPE:
740
ADDRESS:8893 NORTH SIERRA VISTA AVETELEPHONE:
(559) 470-2062
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 3DATE:
12/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Administrator, Liz CastoTIME COMPLETED:
11:35 AM
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On 12/6/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct an Annual Inspection-Infection Control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator, Liz Casto via telephone. Administrator arrived at the facility a short time later. Facility has one central entrance and exit.

Facility tour conducted with Administrator. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette. Facility staff observed to be wearing facial coverings. LPA toured the facility kitchen. LPA observed a 7-day supply of perishable foods and a 2-day supply of perishable foods. LPA observed a 30 day supply of PPE and cleaning supplies.

Faciltiy has 1 shared bedroom and 2 private rooms. Beds in the shared bedroom were observed to be at least 3 feet apart. Bedrooms were stocked with hand sanitizer. Facility bathrooms were stocked with paper towels and liquid soap. Hand-washing signs observed in resident bathrooms. LPA checked residents' medication and observed a 30 day supply. Resident temperature checks are not documented daily. Resident records have updated emergency contact information. Facility staff records reviewed for good health and infection control training.

No deficiencies issued during this inspection.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/20/2021: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020A- RCFE.

Exit interview conducted. A copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Administrator informed to select yes when prompted to send read receipt.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
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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