<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603664
Report Date: 07/19/2021
Date Signed: 07/19/2021 02:37:49 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 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:0CENSUS: 85DATE:
07/19/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Resident Service Director, Levina DuboseTIME COMPLETED:
09:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Eva Torres conducted a case management visit to amend a report that were created on 02/19/21. LPA Torres met with Resident Service Director, Levina Dubose at the front entrance, informed her of the purpose of the visit, and was granted entry. During the visit, LPA obtained the signature on the amended reports. An exit interview was conducted, Licensee Rights (LIC 9058 01/16) along with a copy of this report was provided to Mrs. Dubose and their signature on this form confirms receipt of these rights.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica TorresTELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1