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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601228
Report Date: 11/20/2023
Date Signed: 11/20/2023 04:05:39 PM


Document Has Been Signed on 11/20/2023 04:05 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:ALTA VISTA MANORFACILITY NUMBER:
374601228
ADMINISTRATOR:ANNA WILSONFACILITY TYPE:
740
ADDRESS:625 MARAZON LANETELEPHONE:
(760) 295-0506
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY:15CENSUS: 11DATE:
11/20/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Anna Wilson, AdministratorTIME COMPLETED:
04:15 PM
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On November 20, 2023, the Department held an informal meeting to discuss the death of the Licensee for the facility. In attendance was Regional Manager (RM) Reyna Lacey, Licensing Program Manager (LPM), Jazmond Harris via Teams, Licensing Program Analyst (LPA), Yolanda Delgado and Licensee's facility administrator Anna Wilson and John Wilson.

The following was discussed, Anna Wilson notified the Department of the death and expressed she will continue the operations of the facility. During the meeting she provided a copy of the notarized designation to continue to operate, declaration that she has no criminal convictions.

The designee agreed to provide a copy of the licensee’s death certificate, obituary notice, certification of death from the decedent’s mortuary, or a letter from the attending physician or coroner’s office verifying the death of the licensee, within 20 working days of the licensee’s death. The application will be turned in by December 1, 2023.

Anna will also submit a hospice waiver request by COB 11/22/2023. Anna Wilson was advised to submit the application to: Adult and Senior Care Program Centralized Application Bureau 744 P Street, MS 9-14-8201, Sacramento, CA 95814

When application is received, an Emergency approval to operate (EAO) will be issued.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
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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