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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600716
Report Date: 03/17/2024
Date Signed: 03/17/2024 12:57:44 PM

Document Has Been Signed on 03/17/2024 12:57 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VISTAS HOMEFACILITY NUMBER:
197600716
ADMINISTRATOR:JASSO,CARLOSFACILITY TYPE:
735
ADDRESS:16778 OTSEGO ST.TELEPHONE:
(818) 784-1680
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY: 4CENSUS: 3DATE:
03/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Patrick KnightTIME COMPLETED:
01:09 PM
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at 8:30 am. LPA was greeted by staff and disclosed the purpose of the visit. The administrator was not present at the facility upon LPA Smith arrival.

LPA conducted a tour at 8:55 am of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the living room and kitchen/dining room combination. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents.



LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the three (3) residents currently residing there. Two (2) days of
perishable food observed. The freezer is stocked with meats and frozen vegetables. Pantry next to refrigerator stocked with dry boxed food and canned goods.

Sharps and first aid kit are locked in kitchen drawer. The resident medications are locked in upper kitchen cabinet and observed to be inaccessible to residents. There is one (1) fire extinguisher attached to dining room wall: observed to be charged.

Laundry room is located past kitchen. The appliances observed to be functional. Toxins stored and locked in cabinets across from washer/dryer. Toxins cabinet observed to be locked and inaccessible to residents.
The facility has a total of six (6) bedrooms and three (3) bathrooms: there are three (3) bedrooms and two (2) bathrooms for residents and two (2) bedrooms for staff.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2024
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VISTAS HOME
FACILITY NUMBER: 197600716
VISIT DATE: 03/17/2024
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Cont. from 809)

The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for
each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases,mattress pads, and blankets. LPA observed a supply of linens in laundry room.

Each bathroom had the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for in bathrooms to ensure it within the required range for residents’ comfort and safety. The water temperature range was measured at 118.7 and 120.1-degrees Fahrenheit for the residents’ bathrooms.

Executive Director (Patrick Knight) arrived at approximately 1025 am. There is no body of water in the facility.

Detached Garage: Used for storage of equipment and furniture.

Storage shed used for storage in backyard observed to be locked and inaccessible to residents.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

At approximately 09:30 am LPA Smith reviewed facility files and three (3) residents records. The resident files included medical assessments, admissions agreements, and Individual Personal Programs (IPPs). LPA Smith also reviewed four (4) random staff files. Staff files had the appropriate trainings and current CPR training.

Technical advisory for copies of Individual service plans. No Deficiencies Cited.

Exit Interview Conducted / A Copy of the Report Issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2024
LIC809 (FAS) - (06/04)
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