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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880902
Report Date: 01/09/2025
Date Signed: 01/10/2025 07:58:07 AM

Document Has Been Signed on 01/10/2025 07:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BUENA VISTA ASSISTED LIVINGFACILITY NUMBER:
331880902
ADMINISTRATOR/
DIRECTOR:		GRISELDA GARCIAFACILITY TYPE:
740
ADDRESS:1393 S. BUENA VISTA ST.TELEPHONE:
(951) 658-5160
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 49CENSUS: 32DATE:
01/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
06:00 PM
MET WITH:Robyn RebollarTIME VISIT/
INSPECTION COMPLETED:
08:40 PM
NARRATIVE
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This Case management– Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Abdoulaye Zerbo on 1-9-25 for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 18-AS-20250109153636. LPA met with Robyn Rebollar and explained purpose of the visit.

During the visit, LPA interviewed management and observed that the facility did not report the power outage to the department.

Based on observations, record review and interviews , deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809-D.

An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative, Robyn Rebollar.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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Document Has Been Signed on 01/10/2025 07:58 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 01/09/2025 at 08:04 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/23/2025
Section Cited
CCR
80061(b)(1)(E)

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80061 Reporting Requirements
(b) ...during the operation of the facility... a report shall be made to the licensing agency...(1) Events reported shall include the following(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. Requirement was not being met as evidenced by:
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Licensee will conduct staff training on the reporting requirements and provide proof of training and training material to LPA by the plan of correction date.
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Licensee did not report SIRs to the Department for the power outage that occured on 1-8-25 at 12:30 PM
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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