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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425828
Report Date: 05/10/2023
Date Signed: 05/10/2023 12:59:32 PM

Document Has Been Signed on 05/10/2023 12:59 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VISTA CARE CENTERFACILITY NUMBER:
366425828
ADMINISTRATOR:ANITA N. LAYGOFACILITY TYPE:
735
ADDRESS:25155 VIS VISTA RDTELEPHONE:
(760) 813-3022
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 5CENSUS: 4DATE:
05/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Lead Staff - Paulino EsquilloTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Victoria Chitgian arrived to the facility unannounced for a Case Management- Deficiencies visit.

In reference to Complaint # 56-AS-20230306110239; Upon review of client documents, LPA discovered Client 1 required supervision at all times due to a behavioral condition indicated on record.

Based on interviews with Staff and records review, Client 1 was not provided Staff supervision on 2/1/2023 when taken to Victor Valley Emergency Department. He was unattended in the lobby and waiting room at 9:25PM, and returned home at 2/2/2023 at 12:43AM.

Based on the observations made during today’s visit, one deficiencies was cited per Title 22, Division 6, of the California Code of Regulations. At exit interview was conducted and a copy of this report LIC 809, LIC 809-D and appeal rights was provided to Lead Staff Paulino Esquillo.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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 05/10/2023 12:59 PM - It Cannot Be Edited


Created By: Victoria Chitgian On 05/10/2023 at 12:31 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: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
The licensee failed to comply with the above
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Licensee will read the regulation in full, train all staff on the regulation on care and supervision, and submit training log and understanding to LPA by the POC due date 5/15/2023.
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as observed by not providing client with supervision outside the facility in a public hospital waiting room, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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:Efren Malagon
LICENSING EVALUATOR NAME:Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
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