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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604176
Report Date: 12/22/2021
Date Signed: 12/22/2021 05:38:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
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: DATE:
12/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Diane Domingo, Executive DirectorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit at the facility. LPA Lopez identified herself and was granted entry by Jilian Rogers, Concierge. LPA stated the purpose of the visit and reviewed the basic elements of the complaint with Diane Domingo, Executive Director.

The facility self reported an incident regarding Resident #1 (R1) (See LIC 811 Confidential Names List) to Community Care Licensing on December 21, 2021. The facility reported that on December 7, 2021, R1 eloped from the facility unnoticed and Police Department returned the resident to the facility the same day with no injuries noted.

During today’s visit, LPA conducted interviews and requested and obtained client records. This case management needs further follow-up. No deficiencies were cited during this visit.

An exit interview was conducted with Executive Director Domingo and a copy of this report, LIC 811 and Licensee/Appeal Rights (LIC 9058 01/16) were provided via email. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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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