374604176-10-27-2023-18-AS-CGOH-CWZR6N-20231027124502

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604176
Report Date: 10/27/2023
Date Signed: 10/27/2023 12:45:43 PM

Document Has Been Signed on 10/27/2023 12:45 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ALTA VISTA SENIOR LIVING		FACILITY NUMBER:	374604176
ADMINISTRATOR:	ALSPACH, DAVID		FACILITY TYPE:	740
ADDRESS:	2041 W VISTA WAY		TELEPHONE:	(760) 941-3233
CITY:	VISTA	STATE: CA	ZIP CODE:	92083
CAPACITY:	98	CENSUS: 77	DATE:	10/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Business Office Manager, Monica Flores		TIME COMPLETED:	12:46 PM

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) Cheryl Goodrich arrived at 9:48am to the facility to complete the unannounced required - 1 year annual inspection. LPA met with Business Office Manager, Monica Flores at the front desk and was granted entry. The purpose of today's visit is to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The facility is approved for 98 non-ambulatory residents of which 10 may be bedridden with 77 residents in care. The facility is approved for delayed egress. The facility has a hospice waiver for 15 residents. Infection Control: The facility has an approved infection control plan and a surplus of infection control supplies including but not limited to gloves, masks, gown and cleaning supplies. Operational Requirements: The facility has a plan of operation, an approved infection control plan, and has an approved fire clearance and liability insurance. Physical Plant & Environmental Safety: The facility temperature read at 72 degrees. The facility has 90 bedrooms and bathrooms, living room, kitchen, dining room, theatre room, salon, game room and patio. The bedrooms have beds with clean linen, dresser, TV and closet space. The bedrooms are clean and clear of obstruction. The kitchen, living room and dining room are all clean and clear of obstruction. The medications are kept in med-tech carts and are locked in med-tech rooms, one on each floor for memory care and assisted living and inaccessible to residents in care. The facility has no bodies of water on the premises. Staffing: The facility has 75 staff members on site to care for the 77 residents in care during the day and night. The facility has adequate supervision of the residents in care. (Continued on LIC809-C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ALTA VISTA SENIOR LIVING	FACILITY NUMBER: 374604176
	VISIT DATE: 10/27/2023

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(Continued from LIC809)

Personnel and Training Records: The staff have complete training records containing; applications, Fingerprint clearance, Health and TB screening, and in-service trainings.
Residents Right Information: The facility has posted resident's right information.
Planned Activities: The facility has planned activities for residents based on their mobility and level of comfort.
Food Service: A 7-day non-perishable and 2-day perishable food supply was observed and all food was properly stored and available to residents in care.
Incidental Medical and Dental: The facility has the resident's medication properly stored in the medication carts and in the med-tech room on each floor. The facility documents the distribution of medication in the medication logbook in residents files and the electronic MAR. The facility is in compliance with physician's orders and regulations.
Disaster Preparedness: The facility has an Emergency Disaster Plan with evacuation routes posted for both staff and residents in care. The facility has posted the Emergency phone numbers list. The facility has smoke and carbon monoxide detectors and fire extinguishers that are in working order. The last fire drill was completed on 10/26/23.
Residents with Special Needs: The facility has an approved Hospice Waiver for 15. The facility continues on-going training for residents with special needs and documents the training.
Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Business Office Manager, Monica Flores and a copy of this report was emailed, signature below confirms the receipt of these rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC809 (FAS) - (06/04)

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