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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880902
Report Date: 07/26/2022
Date Signed: 07/26/2022 12:51:29 PM

Document Has Been Signed on 07/26/2022 12:51 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BUENA VISTA ASSISTED LIVINGFACILITY NUMBER:
331880902
ADMINISTRATOR:NEWCOMB, DOLLYFACILITY TYPE:
740
ADDRESS:1393 S. BUENA VISTA ST.TELEPHONE:
(951) 658-5160
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 49CENSUS: 38DATE:
07/26/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Griselda T. Garcia - AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Crystal Colvin, conducted an unannounced visit to the facility to initiate the investigation complaint #18-AS-20220725131214. The LPA Colvin met with Administrator Griselda T. Garciaand informed her of the purpose of the visit.

LPA Colvin observed that the facility has working utilities, plenty of staffing in place, and at least a 2 day supply if perishable food and a 7 day supply of non-perishable food at the time of LPA Colvin's inspection.

No immediate health and safety concerns were observed at this time.

An exit interview was conducted with Administrator Griselda T. Garcia and a copy of this report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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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