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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603664
Report Date: 09/09/2020
Date Signed: 09/09/2020 11:03:25 AM

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 DEL LAGO MEMORY CAREFACILITY NUMBER:
374603664
ADMINISTRATOR:JEFF GONZALEZFACILITY TYPE:
740
ADDRESS:1817 AVENIDA DEL DIABLOTELEPHONE:
(760) 741-2888
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:96CENSUS: 91DATE:
09/09/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Resident Service Director, Levina DuboseTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Eva Torres conducted a virtual case management visit via FaceTime to follow up on incident that was reported by the facility on 09/08/20. LPA identified herself, spoke with Resident Service Director, Levina Dubose, and disclosed the purpose of the phone call.

On 09/08/20, LPA emailed the administrator and requested the records for Resident #1 (R1) (See LIC 811- Confidential Names List for R1). During today's meeting, LPA spoke with the Resident Service Director and obtained additional information surrounding the incident that occurred on 09/02/20.

An exit interview was conducted with Resident Service Director, Levina Dubose, and the Licensee’s Rights (LIC9058 01/16) along with a copy of this report was provided to the Resident Service Director, Dubose via email. A reply email or return receipt from the Resident Service Director will confirm receipt of documents.

SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Evangelica TorresTELEPHONE: (619) 990-1407
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020
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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