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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880835
Report Date: 04/04/2023
Date Signed: 04/05/2023 09:15:03 AM


Document Has Been Signed on 04/05/2023 09:15 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: 20DATE:
04/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Ashley Willett, Executive DirectorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Goldenberg arrived to the facility to conduct a case management visit. The purpose of this case management visit is to conduct a health and safety check and to address noncompliance in regard to Health and Safety Code Section 1569.682. On 03/01/2023 residents of the facility were issued 60-day notice to terminate. In accordance with Health and Safety Code Section 1569.682, until the department has approved a licensee’s closure plan, the facility shall not issue a notice of transfer or require any resident to transfer. Any notice issued prior to 03/14/2023 would not meet statutory and regulatory requirements.
On Thursday, March 23, 2023 at 11:19 AM the failure to meet the requirement was outlined to Ms. Betty Dominici via email. On Thursday 3/23/2023 at 1:26 PM This department received a response from Betty Dominici as follows, " We will be sending out a new notice today."

This department has determined that a violation has occurred and a deficiency is being issued per Health and Safety Code 1569.682.

This report was reviewed with Ashley Willett, Executive Director. Ms. Willett was provided with a copy of 809, 809D, and appeal rights during the exit interview.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
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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Document Has Been Signed on 04/05/2023 09:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MOUNTAIN
FACILITY NUMBER: 361880835

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2023
Section Cited

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 Until the department has approved a licensee’s closure plan, the facility shall not issue a notice of transfer...On 03/01/2023 residents were issued 60-day notice to Terminate. The closure plan was not approved until 3/14/2023.
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Licensee to issue a new 60- day to terminate that is dated post 3/14/2023 to all remaining residents and to the Ombudsmans Office by POC due date 04/05/2023 close of business. LIC 9098 to be submitted self certifying that correction has been made along with a copy of revised letter.

Failure to correct may lead to Civil Penalty Assessment.
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The facility has failed to meet this requirement based on the following: Any notice issued prior to 03/14/2023 would not meet statutory and regulatory requirements. This poses a risk to the health and safety of residents in care.
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A licensee who fails to comply with requirements of this section shall be liable for the imposition of civil penalties in the amount of one hundred dollars ($100) per violation per day for each day that the licensee is in violation of this section, until such time that the violation has been corrected.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2