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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604176
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:35:37 PM


Document Has Been Signed on 10/27/2022 02:35 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Diane Domingo, Executive DirectorTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to follow up on an incident reported by the facility. The Riverside Regional Office was notified on September 30, 2022 of an incident in which a resident in care, Resident One (R1) was slapped by a staff member, Staff One (S1).

On this visit the LPA conducted staff/resident interviews, reviewed records, and took copies of pertinent documentation. A records review revealed four (4) staff statements corroborating the alleged incident took place, including a statement from S1. Records review also revealed the facility, prior to the incident, provided S1 the required training and abuse reporting information. S1 was contacted and admitted they had slapped R1 on the face after the resident spit on them. R1 was interviewed and denied being struck by a staff member. Additional interviews with witnesses corroborated the incident occurred. According to ED Domingo, S1 was immediately suspended on September 29, 2022 and has not returned to the facility. Separation paperwork showed S1 was terminated on October 07, 2022. This incident posed an immediate threat to the health, safety and personal rights of the resident in care. A citation will be issued.

Furthermore, a review of the Department's fingerprint database revealed S1 is pending a fingerprint clearance from the Department. Department records do not show S1 was cleared prior to the date of the incident. Per Domingo, S1 has been employed by the facility since March 2022. This posed a potential threat to the residents in care. A citation and civil penalty will be issued.

An exit interview was conducted; this report was reviewed with the ED and a copy was provided, along with LIC 811, LIC 421BG, and Appeal Rights.
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)
Page: 1 of 2


Document Has Been Signed on 10/27/2022 02:35 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
CCLD Regional Office, 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: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2022
Section Cited

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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES: (a) Residents in all RCFEs shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...
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This requirement was not met, as evidenced by: Based on interviews and records, R1 was not granted the right to be free from punishment/abuse. Written staff statements corroborated the alleged incident took place. Interviews revealed S1 slapped R1 on the face after the resident spit on them.
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Type B
10/27/2022
Section Cited

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CRIMINAL RECORD CLEARANCE: (e) All individuals subject to a criminal record review pursuant to H&S ... 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or... This requirement
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was not met, as evidenced by: Based on record review, the Licensee did not ensure S1 was fingerprint cleared prior to working in the facility. A review of the Department's fingerprint database revealed S1 is pending a fingerprint clearance from the Department.
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
LIC809 (FAS) - (06/04)
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