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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604176
Report Date: 10/09/2024
Date Signed: 10/09/2024 03:07:48 PM


Document Has Been Signed on 10/09/2024 03:07 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
RIVERSIDE ASC, 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: 80DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jennifer Gephart, Executive DirectorTIME COMPLETED:
01:00 PM
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On 10/09/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted and granted entry by Executive Director Jennifer Gephart where LPA explained the purpose of the visit. The facility has an approved fire clearance to accept and retain 10 residents that are bedridden with an approved hospice waiver for (15), there is currently 14 residents receiving hospice services. LPA conducted a tour of the facility, below is a summary of what was observed.

The facility is a two story structure; the first floor consists of facility's assisted living and memory care with delayed egress. There is an activity room, lounge area and dining room located on the first floor. The second floor will service assisted living residents, and also contains a medication room, theater room, beauty salon, and an activity room. The bathrooms were observed to have grab bars, with pull cords and the signal system was tested and observed to be operable. The hot water temperature was tested in resident bathrooms and found to be within regulatory limits of 106.7 degrees Fahrenheit.

Medications were observed to be labeled and in a locked place that is inaccessible to residents. The facility is utilizing an electronic medication authorization record tracking system. The smoke/carbon monoxide detectors were tested and observed to be operable. The facility fire/safety inspection was completed on 07/10/24. The last emergency disaster drill was conducted on 5/24/24, deficiency cited as drills are to be conducted on a quarterly basis and should have been completed in September 2024. The facility was observed to have fully charged fire extinguishers throughout the facility, that were serviced in May 2024. There are no known guns or ammunition on the premises. There are no pools or bodies of water observed at the facility. The outdoor and indoor passageways are free from obstructions.

Food supply: the facility was observed to have a 2 day supply of perishable food items and a 7 day supply of non perishable food items which meets the requirements
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALTA VISTA SENIOR LIVING
FACILITY NUMBER: 374604176
VISIT DATE: 10/09/2024
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Records review: All staff present at the facility were observed to have obtained criminal record clearance and to be associated to the facility. The Executive Director Jennifer was observed to have a valid administrator's certification. Further records review revealed that the facility does not have a staff that is CPR certified working during each shift. Deficiency cited.

Resident files were observed to have medical assessments, admissions agreements and personal rights. The facility was observed to have the required postings such as Long Term Care Ombudsman Poster, CCL complaint poster, personal rights, and license. The facility was observed to not have proof of valid liability insurance, deficiency cited.


Based on today's inspection the deficiencies are being cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). on the attached 809D.

An exit interview was conducted and a copy of this report, LIC809D, LIC9098-Proof of Corrections form, and appeal rights were reviewed and provided to Jennifer Gephart, Executive Director.



SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/09/2024 03:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ALTA VISTA SENIOR LIVING
FACILITY NUMBER: 374604176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records review, the licensee did not comply with the section cited above in 6 out of 8 persons/ staff files reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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The licensee agrees to have staff enroll and complete CPR certification training. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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The Licensee agrees to conduct an emergency disaster drill and document it. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/09/2024 03:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ALTA VISTA SENIOR LIVING
FACILITY NUMBER: 374604176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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The Licensee agrees to obtain valid liability insurance. Proof is to be submitted to the department by 5pm on the due date indicated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4