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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603349
Report Date: 06/29/2021
Date Signed: 06/29/2021 10:14:19 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 VILLAGE CAREFACILITY NUMBER:
374603349
ADMINISTRATOR:DOBRILA MILOSAVLJEVICFACILITY TYPE:
740
ADDRESS:222 WASHINGTON STREETTELEPHONE:
(760) 295-7258
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:12CENSUS: 10DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Milijana Milosavljevic, CaregiverTIME COMPLETED:
03:30 PM
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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 Silvia Mendoza, Caregiver. LPA met with Miljana Vasic, Caregiver and discussed the purpose of today’s visit.

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

During today's inspection LPA observations include the following: Symptom screening procedures/ for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; Hand hygiene practices; testing plan and procedures; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Miljana Vasic, Caregiver. A copy of this report, along with the Licensee Rights (01/2016) was emailed to Miljana Vasic, Caregiver, at the conclusion of the visit. LPA requested Miljana Vasic, Caregiver, to send LPA an electronic message reply confirming receipt of these documents.

LPA requested for Miljana Vasic, Caregiver to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-E 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: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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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