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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604144
Report Date: 04/15/2024
Date Signed: 04/15/2024 11:41:38 AM


Document Has Been Signed on 04/15/2024 11:41 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:MONTE VISTA MANORFACILITY NUMBER:
374604144
ADMINISTRATOR:ILICH, VESNAFACILITY TYPE:
740
ADDRESS:2331 MONTE VISTA DRTELEPHONE:
(760) 536-3114
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 5DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:ADMINISTRATOR, VESNA ILICHTIME COMPLETED:
11:49 AM
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On April 15, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Vesna Ilich. The facility file review was conducted in the Regional Office and additional forms were requested and reviewed on site. The facility is licensed for six Adult Seniors and is currently operating at a capacity of five.

LPA Mixson toured the facility along with the Administrator and inspected the facility inside and outside, there were no obstructions or debris to the indoor or outdoor passageways currently at the time of this visit. The facility is a single-story home located at 2331 Monte Vista Dr Vista Ca. 92084.

Physical Plant: The facility phone number is (760) 536-3114 and is operable currently. The LPA observed the residents’ bedrooms, each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. 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. The LPA observed required postings such as "If you See Something, Say Something" the "Personal Rights" and the Ombudsman postings. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit.

Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. 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, and there were safety lights for night through out the facility.

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, and sharps are locked.

Care & Supervision: Facility has sufficient staff, three staff on site at the time of this visit and were engaging the residents with medication management and meals.

Records Review: The LPA reviewed resident and staff files, conducted staff interviews, and observed a resident during transition, the other residents were in the community. 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 Administrator, Vesna Ilich.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
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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