<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423475
Report Date: 10/27/2022
Date Signed: 10/27/2022 10:51:22 AM


Document Has Been Signed on 10/27/2022 10:51 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:SIERRA VISTAFACILITY NUMBER:
366423475
ADMINISTRATOR:GONZALES, MARIA IFACILITY TYPE:
740
ADDRESS:13815 RODEO DRTELEPHONE:
(760) 243-2271
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:63CENSUS: 40DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Kimberly Mejia, AdministratorTIME COMPLETED:
10:55 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility for the purpose of conducting a required annual inspection with an emphasis on infection control. LPA met with executive director Kimberly Mejia (ED) who was informed of the reason for today's visit. LPA observed a single entry point to the main lobby with a sign-in policy for universal entry screening.

ED and LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. LPA observed that the facility had several COVID-19 related postings and hand sanitizer stations throughout the facility. This facility was also equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions, and a 30+ day supply of Personal Protective Equipment (PPE). LPA Bueno observed all staff members were properly fitted with face coverings.

This facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents with COVID-19 positive result and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify responsible parties and medical personnel in the event residents present with any COVID-19 symptoms.

During the tour, LPA and ED made observations of the physical plant. Fire extinguishers were observed to have tags dated 9/29/2022. ED Mejia confirmed that the sprinkler systems and kitchen fire equipment are maintained by a third party vendor and was inspected on 9/22/2022. All common areas of the facility, including kitchen, restrooms, and hallways were kept tidy and free from obstruction. LPA Bueno observed no health and safety concerns at the time of visit.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: SIERRA VISTA
FACILITY NUMBER: 366423475
VISIT DATE: 10/27/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where a copy of this report was discussed with and provided to executive director Kimberly Mejia at the conclusion of today's inspection.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2