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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700652
Report Date: 03/11/2022
Date Signed: 03/11/2022 04:59:51 PM

Document Has Been Signed on 03/11/2022 04:59 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:VISTA DE ROBLESFACILITY NUMBER:
342700652
ADMINISTRATOR:GARRETT JOHNSONFACILITY TYPE:
735
ADDRESS:9847 FOLSOM BLVDTELEPHONE:
(916) 368-7186
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY: 80CENSUS: DATE:
03/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Naidy Lozada.TIME COMPLETED:
05:00 PM
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On 3/11/22 at 9:00am, Licensing Program Analysts (LPAs) Kevin Gould and Anthony Tuck conducted an unannounced Case Management inspection at Vista De Robles ARF. LPAs met with Administrator Garrett Johnson and backup administrator Naidy Lozada.

The Department has determined the complaint dated 11/25/2020 required additional investigation. the Department has conducted additional investigation including additional staff interviews and review of client records. Staff interviewed denied that R1 had expressed feeling suicidal. Staff interviewed did not have evidence to suggest R1 was using drugs at the time of her death. R1's clinical and mental health records were obtained and reviewed by the department. Review of resident records did not indicate that R1 expressed suicidal intent to her clinicians.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegation of Questionable Death is unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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