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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880835
Report Date: 07/24/2020
Date Signed: 07/24/2020 02:35:31 PM

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:VISTA BLUE MOUNTAINFACILITY NUMBER:
361880835
ADMINISTRATOR:TRABUCCO, MEGANFACILITY TYPE:
740
ADDRESS:22325 BARTON ROADTELEPHONE:
(909) 420-0153
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:150CENSUS: 71DATE:
07/24/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Jacqueline Penn, Executive DirectorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Robbie Johnson contacted the facility via telephone due to COVID-19
for the purpose of investigating the death of resident (R1). LPA identified herself and discussed the purpose of the call with Executive Director Jacquline Penn.

During the telephone call, LPA conducted interviews with Executive Director Jacqueline Penn to obtain additional information regarding the incident.

The licensee is responsible for obtaining the death certificate. The licensee will fax a copy of the death certificate to the licensing department once it is obtained. The investigation will continue until the cause of death is known.

No deficiencies were cited during the tele visit. An exit interview was conducted where this report was discussed and provided to the Executive Director.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Robbie JohnsonTELEPHONE: (951) 248-0304
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020
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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