374601228-4-4-2025-18-AS-APEZ-DFELQQ-20250404085751

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601228
Report Date: 11/14/2024
Date Signed: 04/04/2025 08:58:04 AM

Document Has Been Signed on 04/04/2025 08:58 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ALTA VISTA MANOR		FACILITY NUMBER:	374601228
ADMINISTRATOR/ DIRECTOR:	ANNA WILSON		FACILITY TYPE:	740
ADDRESS:	625 MARAZON LANE		TELEPHONE:	(760) 295-0506
CITY:	VISTA	STATE: CA	ZIP CODE:	92083
CAPACITY: 15	TOTAL ENROLLED CHILDREN: 0	CENSUS: 10	DATE:	11/14/2024
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:40 AM
MET WITH:	Administrator Anna Wilson		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE

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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.

Jazmond D Harris	TELEPHONE: (951) 529-2439
Armando Perez	TELEPHONE: (951) 248-2222
	DATE: 11/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

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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