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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603415
Report Date: 01/03/2025
Date Signed: 01/03/2025 11:26:11 AM

Document Has Been Signed on 01/03/2025 11:26 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:VERSATILE RESIDENTIAL CAREFACILITY NUMBER:
374603415
ADMINISTRATOR/
DIRECTOR:		ANNABELLE BARRETOFACILITY TYPE:
735
ADDRESS:1830 GOODWIN DRIVETELEPHONE:
(760) 536-3265
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 6CENSUS: 6DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:FACILITY MANAGER, VANGIE LORENZOTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On January 03, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the required annual inspection and met with the Facility Manager, Vangie Lorenzo, and stated the purpose of the visit.

LPA Mixson toured the facility and inspected the facility inside and outside. There were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single-story home, located at 1830 Goodwin Drive Vista, CA. 92084.

Physical Plant: The facility phone number is (760) 536-3265 and is operable. LPA observed the residents’ bedrooms, and they are equipped with required furniture as per Title 22. LPA inspected facility bathrooms, and the hot water temperature was tested and tested within regulations. Facility Manger shared that the hot water is tested once a week on Monday and logged. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. Fire extinguishers were check by the local fire department.

LPA observed required postings such as "If you See Something, Say Something" the "Personal Rights" and the Inland Regional Rights of the Residents. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the resident and staff files it was locked and inaccessible to residents in care.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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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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: VERSATILE RESIDENTIAL CARE
FACILITY NUMBER: 374603415
VISIT DATE: 01/03/2025
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Medications: were reviewed, locked and inaccessible to residents, and there was a 30 day supply. The overall facility is clean, the furniture is in good condition. The facility heating system and other appliances were operable currently at the time of this visit.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly.

Care & Supervision: Facility has sufficient staff, one staff at the time of this visit, residents are at the day program. This is for daily activity, and social skills building.

Records Review:
LPA Mixson reviewed resident and staff files. The LPA Conducted staff interview, residents in the community at the Day Program. Previous Community Care Licensing forms were reviewed. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit.

An exit interview was conducted and a copy of this report was given to the Facility Manger, Vangie Lorenzo.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
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