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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881533
Report Date: 07/12/2024
Date Signed: 07/12/2024 10:54:24 AM


Document Has Been Signed on 07/12/2024 10:54 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
RIVERSIDE, CA 92507



FACILITY NAME:ALTA VISTA MANORFACILITY NUMBER:
371881533
ADMINISTRATOR:WILSON, JOHNFACILITY TYPE:
740
ADDRESS:625 MARAZON LANETELEPHONE:
(760) 298-0506
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY:15CENSUS: 11DATE:
07/12/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:ADMINISTRATOR, ANNA WILSONTIME COMPLETED:
11:00 AM
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On July 12, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a case management health and safety visit. LPA met with administrator, Anna Wilson.

LPA Mixson toured the facility, along with the Administrator, and made observations. LPA reviewed records and inspected the facility inside and out and requested and received pertinent documentation. LPA conducted record reviews to include the Emergency Approval to Operate, (LIC 9117), LIC 9020 Roster of Facility Clients/Residents, and Personal Roster (LIC 500). Administrator informed LPA that the Fire clearance inspection is scheduled for 07/17/2024.

LPA observed the facility utilities to be operating without issue and assessed the available food. There was a variety of food types available for the residents in care and the food supply meets the requirement of a two-day supply of perishable foods and a seven-day supply of non-perishable foods. The medications were found to be in sufficient supply, locked, and inaccessible to the residents in care.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. No deficiencies were observed or cited during today's visit.

An exit interview was conducted, and a copy of this report was provided to Administrator, Anna Wilson.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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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