371881458-10-3-2023-18-AS-JSRS-CW9Q9A-20231003115801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881458
Report Date: 10/03/2023
Date Signed: 10/03/2023 12:00:57 PM

Document Has Been Signed on 10/03/2023 12:00 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	VISTA ELDER CARE		FACILITY NUMBER:	371881458
ADMINISTRATOR:	SUBOTIC, NIKOLA		FACILITY TYPE:	740
ADDRESS:	1756 CLUB HEIGHTS LN		TELEPHONE:	(760) 828-7226
CITY:	VISTA	STATE: CA	ZIP CODE:	92081
CAPACITY:	6	CENSUS: 0	DATE:	10/03/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Nikola Subotic, Administrator		TIME COMPLETED:	12:00 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) Jacqueline Shaw Ross conducted an announced Pre-licensing visit at Vista Elder Care for licensure. The LPA was greeted and granted entrance into the home by Administrator, Nikola Subotic. Application: The application is for an Residential Care Facility for the Elderly. The fire clearance has been granted for six (6) non-ambulatory clients for a total capacity of six (6) clients in care. There is an approved hospice waiver for six (6). Buildings and Grounds: The home is a six (6) bedroom, three (3) bathroom one story home, composed of six (6) client bedrooms, a laundry room, three (3) bathrooms, a living room, kitchen and dining area, a bonus room for staff, garage and a backyard area. The exterior pathways of the home were observed to be clutter free with no obstructions present. There are no pools or other bodies of water located at the home. Interior passageways were clear and free of obstruction. The bedrooms are completely furnished with a bed, night stand, dresser, chair, adequate lighting and privacy is available. Night lights were observed in the hallways. The facility currently has linens, towels and a sufficient amount of hygiene products for clients. According to Administrator, there are no weapons stored in the home. Rooms, furniture ,beds, mattresses are all in good repair. The dining and living room areas are clutter free and appropriately furnished. The hot water temperature was tested and measured at 112 degrees Fahrenheit, which was within regulatory limits. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer are available and in working order. Smoke and Carbon Monoxide detectors were tested and operable. The phone number designated for the facility is (760) 536-9234. The fire inspection was conducted and approved on 6/15/2023. The emergency exits are free of obstruction. The facility has an alarm system. Continue on LIC809C....

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA ELDER CARE	FACILITY NUMBER: 371881458
	VISIT DATE: 10/03/2023

NARRATIVE

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Storage and Supplies: Medications will be stored inaccessible to any unauthorized individuals. Secured areas are available for facility files and client files. The First Aid kit was observed to be available and complete. Cleaning supplies will be stored away in a locked cabinet in the laundry room. Linens, personal hygiene supplies, and equipment are all in good repair and sufficient for approved census. Bathrooms were observed to have grab bars, non-slip bath mats, closed-lid waste baskets, and hand-washing signage posted by the sinks. Three (3) fire extinguishers are available and fully charged.

Food Service: The kitchen was observed to have dishes, silverware, pots, and pans. Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps are stored in a secured kitchen drawer, available only to authorized individuals. The refrigerator temperature measured 40 degrees.

Forms: The following forms were observed to be posted at the home: Emergency Disaster Plan (LIC 610D), Personal Rights, and Facility Sketch (LIC 999), Labor Law Information as well as other signage throughout the facility.

The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure. This report was discussed with and a copy provided to Administrator, Nikola Subotic .

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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