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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604176
Report Date: 12/01/2022
Date Signed: 12/01/2022 03:19:27 PM


Document Has Been Signed on 12/01/2022 03:19 PM - 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:ALTA VISTA SENIOR LIVINGFACILITY NUMBER:
374604176
ADMINISTRATOR:ALSPACH, DAVIDFACILITY TYPE:
740
ADDRESS:2041 W VISTA WAYTELEPHONE:
(760) 941-3233
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY:98CENSUS: 75DATE:
12/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Diane Domingo, Executive DirectorTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into complaint #18-AS-20221130130504. The LPA met with Executive Director (ED), Diane Domingo, and informed her of the purpose of her visit.

The LPA toured the interior/exterior areas of the facility. No health and safety concerns were observed at time of visit.

This report was reviewed with Domingo and a copy was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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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