374604176-10-1-2025-18-AS-JGEE-DM2SBW-20251001134437

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604176
Report Date: 10/01/2025
Date Signed: 10/01/2025 01:44:54 PM

Document Has Been Signed on 10/01/2025 01:44 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 LIVING		FACILITY NUMBER:	374604176
ADMINISTRATOR/ DIRECTOR:	JENNIFER GEPHART		FACILITY TYPE:	740
ADDRESS:	2041 W VISTA WAY		TELEPHONE:	(760) 941-3233
CITY:	VISTA	STATE: CA	ZIP CODE:	92083
CAPACITY: 98		CENSUS: 83	DATE:	10/01/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Destiny Quijada, Activities Director		TIME VISIT/ INSPECTION COMPLETED:	01:00 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	On 10/01/25 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 Destiny Quijada, Activities Director, where LPA explained the purpose of the visit. The facility has an approved fire clearance for ten (10) residents that are bedridden with an approved hospice waiver for (15). The administrator was not at the facility at the time the inspection was conducted. Below are the observations made during today's visit: The facility was observed to be clean, with the passageways being from of obstructions. The food supply was sufficient as there was a 2 day supply of perishable food items and a 7 day supply of non perishable food items. The chemicals, and other hazardous items were observed to be locked and inaccessible to residents in care. The resident bedrooms were observed to have the required furniture such as bed, chair, chest of drawers,night stands and light. The bathrooms were observed to have grab bars, with pull cords and the signal system was tested and observed to be operable, in addition residents are provided with pendants . The hot water temperature was tested in randomly selected resident bathrooms and found to be within regulatory limits of 113.8 degrees Fahrenheit. The medications are stored in a locked medication room inside medication carts. The fire extinguishers were last serviced 05/18/25. The last emergency disaster drill was conducted on 09/15/25. There are no known guns or ammunition on the premises. There are no pools or bodies of water observed at the facility. The facility annual fees were observed to have been paid. The facility is in possession of valid liability insurance that expires on 04/20/26, and the governing body was observed to be in good standing.

NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ALTA VISTA SENIOR LIVING	FACILITY NUMBER: 374604176
	VISIT DATE: 10/01/2025

NARRATIVE

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Records review: Per the Guardian personnel roster 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 with a certificate that expires on 03/21/27, as well as CPR certification that expires on 11/06/25. However a records review of four (4) staff files revealed the files are incomplete, as there are records missing such as criminal record statement, proof of 20 hours of completed training and health screening report. Additionally LPA observed for there to not be proof of valid CPR certification. Deficiency cited.

Resident files were observed to have updated medical assessments, appraisals and admissions agreements.

The facility is to submit an updated emergency disaster plan LIC610E, by 5pm on 10/6/25.

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 immediate civil penalty of $250 is being assessed due to a repeated violation within a 12 month period.

An exit interview was conducted and a copy of this report, LIC809D, LIC421FC, LIC9098-Proof of Corrections form, and appeal rights were reviewed and provided to Destiny Quijada, Activities Director.

NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/01/2025 01:44 PM - It Cannot Be Edited

Created By: Javina George On 10/01/2025 at 12:56 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/01/2025

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 times which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/02/2025
	Plan of Correction
1 2 3 4	The Licensee agrees to provide proof of CPR certification for the (4) staff reviewed on the LIC811. If this does not apply then enroll and have the (4) staff complete the training. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Carolyn Tuba
NAME OF LICENSING PROGRAM MANAGER:

	Javina George
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/01/2025 01:44 PM - It Cannot Be Edited

Created By: Javina George On 10/01/2025 at 12:56 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 persons which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2025
	Plan of Correction
1 2 3 4	The Licensee agrees to review staff files according to the LIC311F, submit a list of employee files reviewed attesting that the records are in the employee personnel file. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Carolyn Tuba
NAME OF LICENSING PROGRAM MANAGER:

	Javina George
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

LIC809 (FAS) - (06/04)

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