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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604176
Report Date: 10/27/2022
Date Signed: 11/03/2022 01:39:30 PM


Document Has Been Signed on 11/03/2022 01:39 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: 72DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Diane Domingo, Executive DirectorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA signed in and utilized hand sanitizer. The LPA met with Executive Director (ED), Diane Domingo, and informed her of the purpose of her visit. There are currently no cases of COVID-19 within the facility.

During today's visit, the LPA toured the facility and made observations pertaining to the facility's infection control measures. The LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of Personal Protective Equipment (PPE) and overall infection control. The facility has a Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report in place, which is pending review by the Department.

Based on the observations made during today’s visit, no citations were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations. An exit interview to review this report was conducted 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: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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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