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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880835
Report Date: 03/28/2023
Date Signed: 03/28/2023 10:48:58 AM


Document Has Been Signed on 03/28/2023 10:48 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
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: 33DATE:
03/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH: Ashley Willett, AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Amy Goldenberg is conducting this case management visit to conduct a health and safety check. During this visit LPA gathered resident information regarding resident move outs, toured the kitchen, memory care, and assisted living areas of the facility. LPA observed working electricity, water and that the food supply is meeting regulatory requirements. LPA was provided with a census and learned that 33 residents continue to reside at this location. LPA received a copy of the resident relocation tracking that the facility is maintaining, a copy of the current resident census, and a copy of the revised the 60-day notice letters. LPA was provided with contact information for Ombudsman for verification that they were provided a copy of the revised letter. LPA conducted resident interviews during this visit.

LPA does not identify any health and safety concerns as a result of this visit.

LPA reviewed this report with and provided a copy to Ashley Willett, Administrator.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
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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