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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880835
Report Date: 05/02/2023
Date Signed: 05/02/2023 11:29:48 AM


Document Has Been Signed on 05/02/2023 11:29 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: 0DATE:
05/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Ashley Willett, AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Amy Goldenberg arrived to the facility to conduct a case management visit. LPA was informed by Ashley Willets that the last resident had moved from the facility. The purpose of this visit is to verify that all residents have relocated. LPA tour of the facility verified that there are currently no residents still living at this location.

LPA reviewed and provided a copy of this report to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023
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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