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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601228
Report Date: 03/12/2024
Date Signed: 03/12/2024 11:38:52 AM

Document Has Been Signed on 03/12/2024 11:38 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:
374601228
ADMINISTRATOR:ANNA WILSONFACILITY TYPE:
740
ADDRESS:625 MARAZON LANETELEPHONE:
(760) 295-0506
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY: 15TOTAL ENROLLED CHILDREN: 0CENSUS: 9DATE:
03/12/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Anna Wilson, AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA), Yolanda Delgado arrived unannounced to conduct a case management health and safety visit, and met with the Administrator, Anna Wilson. LPA Delgado introduced herself and explained the purpose of the visit.

LPA Delgado toured the facility, along with the Administrator and made observations and requested and received pertinent documents. There are no imminent health and/or safety concerns observed at the time of visit.

LPA Delgado did not observed any health and/or safety hazards inside or outside of the facility at the time of this visit; LPA observed perimeter with a locked secured black iron gate with a sounding alarm when opened. LPA observed all facility utilities to be on and operating without issue. LPA observed bedroom #11 that is designated as a bedridden room according to fire clearance with a non-bedridden resident; LPA observed bedroom #6 non-bedridden room with a bedridden resident. The LPA 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. One (1) deficiencies were observed and cited during today's visit.

An exit interview was conducted and a copy of this report, LIC 809D and Appeal Rights was provided to the Administrator, Anna Wilson.

Jazmond D HarrisTELEPHONE: (951) 248-0318
Yolanda DelgadoTELEPHONE: (951) 203-2990
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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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Document Has Been Signed on 03/12/2024 11:38 AM - It Cannot Be Edited

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: ALTA VISTA MANOR
FACILITY NUMBER: 374601228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/14/2024
Section Cited
HSC
87202(a)(2)

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FIRE CLEARANCE:
All facilities shall maintain a fire clearance approved...County fire department, or district providing fire protection services, or the State Fire Marshal...(2) Bedridden persons
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Administrator will submit a plan regarding the room change. Administrator will ensure the current approved fire clearance is followed. Administrator will submit the plan by the POC due date.
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This requirement is not being met as evidenced by: LPA Delgado observed (1) bedridden resident in a non-bedriddgen room according to the approved fire clearance. This poses a potential health and safety risk to the clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jazmond D HarrisTELEPHONE: (951) 248-0318
Yolanda DelgadoTELEPHONE: (951) 203-2990

DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024

LIC809 (FAS) - (06/04)
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