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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881533
Report Date: 11/14/2024
Date Signed: 11/14/2024 12:36:36 PM

Document Has Been Signed on 11/14/2024 12:36 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ALTA VISTA MANORFACILITY NUMBER:
371881533
ADMINISTRATOR/
DIRECTOR:		WILSON, JOHNFACILITY TYPE:
740
ADDRESS:625 MARAZON LANETELEPHONE:
(760) 298-0506
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY: 15CENSUS: 10DATE:
11/14/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Administrator Anna WilsonTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On November 14, 2024, Licensing Program Analysts (LPAs), Armando Perez and Abdoluaye Zerbo arrived unannounced to conduct a case management health and safety visit. LPAs met with administrator, Anna Wilson.

LPAs conducted record reviews to include the Emergency Approval to Operate (EAO), (LIC 9117), LIC 9020 Roster of Facility Clients/Residents, and Personnel Roster (LIC 500). LPAs observed the EAO with the expiration date of November 13, 2024. An additional request is pending. Administrator informed LPAs that the Fire clearance inspection is pending repair work on the sprinkler system. The administrator stated that five companies are bidding for the repair and two companies, by the name of Fire ETC and Spencers Fire are providing estimates today.

LPAs did not observe any health and/or safety hazards inside or outside of the facility at the time of this visit. LPAs observed all facility utilities to be on and operating without issue. LPAs assessed the available food supply and observed there was a variety of food types, and the supply exceeds 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 and are delivered by Quality Care Pharmacy.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and 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 the Administrator, Anna Wilson.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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