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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880835
Report Date: 03/21/2023
Date Signed: 03/21/2023 12:04:19 PM


Document Has Been Signed on 03/21/2023 12:04 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
, CA 92507



FACILITY NAME:VISTA BLUE MOUNTAINFACILITY NUMBER:
361880835
ADMINISTRATOR:ASHLEY WILLETTFACILITY TYPE:
740
ADDRESS:22325 BARTON ROADTELEPHONE:
(909) 420-0153
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:150CENSUS: 46DATE:
03/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley Willett, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Amy Goldenberg is conducting this unannounced case management visit to gather information regarding the facility closure plan. LPA met with Administrator Ashley Willett and disclosed the nature of the visit. During this visit LPA gathered resident information and was provided with identification and emergency information and physician's reports for the remaining residents residing in the facility. LPA reviewed and received a copy of the resident relocation tracking that the facility is maintaining and a copy of the current resident census.

There are no deficiencies being cited as a result of this visit. This report is being reviewed with and a copy provided to Administrator Ashley Willett.





SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
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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