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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425828
Report Date: 02/03/2022
Date Signed: 02/03/2022 02:17:53 PM

Document Has Been Signed on 02/03/2022 02:17 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
RIVERSIDE, CA 92507
FACILITY NAME:VISTA CARE CENTERFACILITY NUMBER:
366425828
ADMINISTRATOR:LAYGO, ARMANDOFACILITY TYPE:
735
ADDRESS:25155 VIS VISTA RDTELEPHONE:
(760) 813-3022
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 5CENSUS: 5DATE:
02/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Sherryann EsquilloTIME COMPLETED:
02:30 PM
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) Melody Brown made an unannounced visit to the facility 02/03/2022 at 11:45 AM to conduct an annual inspection, with emphasis on infection control. LPA was greeted and granted entrance by Assistant Lead Caregiver Sherryann Esquillo and LPA explained the purpose of today's visit. Operation Manager Cielita Ravelo was contacted and informed of the visit but unable to come to the facility. Assistant Lead Caregiver Esquillo accompanied LPA Brown on a tour of the inside and outside of the facility.
During today’s visit, LPA Brown made observation pertaining to the facility’s current infection control measures. LPA Brown observed a screening area, proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and clients for COVID-19, when and how to isolate/quarantine client, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor client regularly for any changes in condition and to subsequently notify the client’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

LPA Brown reviewed the facility’s Covid-19 training for facility staff and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. LPA Brown inquired as to if staff have been fit tested for N95 masks, and Assistant Lead Caregiver Esquillo informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks.

*** Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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 4
Document Has Been Signed on 02/03/2022 02:17 PM - It Cannot Be Edited


Created By: Melody Brown On 02/03/2022 at 01:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA CARE CENTER
FACILITY NUMBER: 366425828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
121125,120140,120175


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in 1/9 staff by not ensuring the personal rights of persons in care to live in a safe, healthy comfortable home, failed to comply with reporting and personnel requirements and engaged in conduct inimical to the health, welfare and safety of persons in care, in that licensee did not verify worker's vaccination, booster or exemption status or unvaccinated workers' test results, as applicable, by maintaining a record as required by State Public Health Officer Order of December 22, 2021 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2022
Plan of Correction
1
2
3
4
Licensee will submit Staff 1 proof of vaccination to LPA Brown by POC due date and will also update Staff 1 vacciination record file at the facility.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
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
RIVERSIDE, CA 92507
FACILITY NAME: VISTA CARE CENTER
FACILITY NUMBER: 366425828
VISIT DATE: 02/03/2022
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
LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive clients, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, most clientts and staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown informed Assistant Lead Caregiver Esquillo the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

LPA Brown reviewed staff vaccination records and on 02/03/2022 at 12:30 PM, LPA Brown observed missing vaccination record of Staff 1 (S1). Assistant Lead Caregiver Esquillo reported that S1 still has not submitted proof of vaccination card and they are giving S1 until tomorrow, 02/04/2022 to provide proof of vaccination or be suspended or terminated. LPA Brown will be issuing a deficiency for failure to keep records of Worker’s Vaccination which can pose immediate risk to clients in care

An exit interview was conducted with Assistant Lead Caregiver Esquillo and a copy of this report (LIC809), LIC809D, LIC9102 TA Advisory Notes and Appeal Rights were provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4