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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601357
Report Date: 06/23/2021
Date Signed: 06/23/2021 04:02:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:VISTA ROYAL ASSISTED LIVINGFACILITY NUMBER:
374601357
ADMINISTRATOR:DJORDJEVIC, SASAFACILITY TYPE:
740
ADDRESS:2336 VISTA ROYALTELEPHONE:
(760) 598-1435
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 4DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sasa Djordjevic, LicenseeTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez, made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself and was granted entry by Sasa Djordjevic, Licensee. LPA met with Sasa Djordjevic, Licensee and discussed the purpose of today’s visit.

A tour of the facility was conducted inside and out. LPA accompanied by Sasa Djordjevic, Licensee, and conducted a general overall inspection, with specific focus on infection control protocols.

During today's inspection LPA observations include the following: Symptom screening for staff, residents and visitors; infection control procedures; Hand hygiene practices; testing plan and procedures; plans for containing infections; and disinfection procedures.

LPA Lopez gave technical advisory on posted signs promoting hand washing, cough and sneeze etiquette, sign-in policy for visitors; and PPE supplies procedures and training.

Based on today’s inspection, a deficiency was observed at this time in the areas evaluated and are documented on LIC 809-D. This report was discussed with Sasa Djordjevic, Licensee. A copy along with Licensee Rights (01/2016) was emailed to Sasa Djordjevic, Licensee at the conclusion of the visit and an electronic response confirms the receipt of these documents.

LPA requested for Sasa Djordjevic, Licensee to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-D to the licensing office within 10 business days. Forms available at www.ccld.ca.gov.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VISTA ROYAL ASSISTED LIVING
FACILITY NUMBER: 374601357
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)


This requirement is not met as evidenced by: 87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering at a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that one out of one staff person did not have a criminal record exemption clearance which poses an immediate safety risk to persons in care.
POC Due Date: 06/23/2021
Plan of Correction
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Licensee had individual sent home until a record clearance is obtained. Licensee will be sending individual to be fingerprinted June 24, 2021. Licensee will submit documents upon completion to CCL by June 30, 2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
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