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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881719
Report Date: 04/11/2025
Date Signed: 04/11/2025 04:25:24 PM

Document Has Been Signed on 04/11/2025 04:25 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 SENIOR LIVING, LLCFACILITY NUMBER:
371881719
ADMINISTRATOR/
DIRECTOR:		KAKANI, SHRIKANTFACILITY TYPE:
740
ADDRESS:222 WASHIGTON STTELEPHONE:
(619) 791-5495
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 13CENSUS: 0DATE:
04/11/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:ADMINISTRATOR, SHRIKANT KAKANI TIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On April 11, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived for a scheduled visit for the purpose of conducting a Pre-Licensing visit, (CHOW). LPA Mixson met with Kakani Shrikant, Administrator, introduced herself, and stated the purpose of the visit.LPA toured the location along with the Administrator and made observations following is a summary.

Physical Plant: The location is a single-story facility located at 222 Washington Ave Vista CA 92084, and has nine bedrooms, seven bathrooms, a living room, dining room, and a kitchen. A backyard and front drive-in space. The Vista Fire Department approved this facility for seven non-Ambulatory, zero-Ambulatory, and six bedridden residents, on March 21, 2025. The home has a first aid kit and manual, the Administrator has received First Aid and CPR training, and the Administrator’s certificate is current, and Posted.

Medications: LPA Mixson observed where medications are to be stored, locked, and inaccessible to the residents. The home is equipped with lights in the passages and stocked with emergency night lights throughout the home. The smoke and carbon monoxide detectors were observed and are operable. LPA Mixson observed two brand new fire extinguishers, charged and in the green, and obtained on 03/03/2025. The cleaning supplies were locked and inaccessible, along with the sharp objects and the Administrator informed the LPA there are no firearms on the premises.

Bedrooms: Nine (9) bedrooms were observed and are large enough to allow for easy passage. The required items of furniture were discussed currently at the time of this inspection. Chair, nightstand, and sufficient lighting for future residents.
NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Venus Mixson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VISTA SENIOR LIVING, LLC
FACILITY NUMBER: 371881719
VISIT DATE: 04/11/2025
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Kitchen/Food: The knives were locked in a kitchen drawer, plenty of pots, pans, and other kitchen accessories. The facility has the required seven-day supply of non-perishable food items. LPA Mixson observed hygiene supplies for residents. There were no pesticides, poisons, or other toxic substances stored in any food storage or preparation area currently at the time of this inspection. (87555).
Records: There is confidential storage space for personnel records at the time of this visit. (87412). Bathrooms: The (7) bathrooms floors were clean and sanitary and free of odors. Other appliances were operable, water temperature tested within regulations, and was logged. There was at least one toilet and sink for each six persons to include residents, family, and personnel. (87307), and at least one bathtub/shower for each ten persons which includes residents, family and/or live-in personnel. (87307).
Administration: LPA Mixson observed emergency exiting plans and telephone numbers posted, Personal Rights, Complaint Poster, and other required documents were posted currently at the time of this visit, along with the current Administrators certification, which has an expiration date of 10/09/2025. The facility theft and loss program policy are posted (87218). Activities: There are activity supplies and equipment, including access to a variety of reading materials in the language of choice. There is an outdoor activity area equipped for outdoor use. (87219).
Miscellaneous: There is a first aid kit, including sterile dressings, bandages, thermometer, and other items as required by regulations. (87465). There are laundry supplies and equipment and there is space for clean linen storage and a separate space for soiled linen. (87307). LPA Mixson observed emergency lighting supplies to include flashlights, and extra batteries. (87303). Dementia Care: There were no bodies of water on the premises currently at the time of this visit, and there are auditory devices in place to monitor exits and completely enclosed outdoor activity space with self-closing latches and gates. (87705).
Inside/Outside: All doors, and passageways are clear of obstruction. There were no bodies of water on the premises, and the fireplace was covered with a screen. There was enough clean linen and hygiene items, and there was appropriate lighting in each room. LPA Mixson observed central heating and air conditioning systems, and they are operable. The Administrator dialed the land line phone number (760) 936-8887, and it was operable. Outside/Yards: Had shade and covering for shaded visits, and activities. There were no obstructions observed. The Licensee stated there were no firearms, and/or ammunition on the premises. CAB 8.0 Pre-licensing / COMP III requested and scheduled. An exit interview was conducted, a copy of this report was provided to the Administrator, Shrikant Kakani.
NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Venus Mixson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC809 (FAS) - (06/04)
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