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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604198
Report Date: 07/31/2023
Date Signed: 07/31/2023 04:00:14 PM


Document Has Been Signed on 07/31/2023 04:00 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:VISTA GARDENSFACILITY NUMBER:
374604198
ADMINISTRATOR:SANCHEZ, PAZ HILDAFACILITY TYPE:
740
ADDRESS:1863 DEVON PLACETELEPHONE:
(760) 295-3900
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:99CENSUS: 86DATE:
07/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Hilda Paz - Executive DirectorTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez made an unannounced visit to the home to commence a complaint investigation regarding personal rights, 18-AS-20230728130208, and met with Executive Director Hilda Paz.

LPA toured the facility and conducted observations, record reviews, and interviews.
During the visit, staff interviews, and record reviews revealed the five (5) staff working are not associated to the facility.

During record review for the complaint investigation, LPA observed the facility did not have an admission's agreement for resident # 1 (R1).

Based on LPA observations, interviews, and record reviews, a deficiency will be issued and civil penalties assessed per California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted where a copy of this report, LIC809D, civil penalties, and appeal rights was provided to Executive Director Hilda Paz.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
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 3


Document Has Been Signed on 07/31/2023 04:00 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: VISTA GARDENS
FACILITY NUMBER: 374604198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2023
Section Cited
CCR
87355(e)(2)

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87355 CRIMINAL RECORD CLEARANCE (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance...
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Licensee will have the five staff members associated to the facility by agreed POC date 08/01/2023. Civil penalty will be assessed.
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This requirement is not met as evidenced by: Based on file review & interview, the licensee did not ensure five (5) employees to be associated to the facility prior to working. Which is an immediete health and safety risk and/or personal rights violation to residents in care.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/31/2023 04:00 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: VISTA GARDENS
FACILITY NUMBER: 374604198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2023
Section Cited
CCR
87507(a)

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ADMISSION AGREEMENT: The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement was not met as evidenced by: Based on records review and interview, the Licensee did not ensure
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The Administrator stated a statement will be submitted ensuring Admission Agreements will be completed for newly admitted residents by the agreed POC date 08/07/23. Due to R1 being discharged on 07/31/23, no admission agreement is needed.
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Admission agreement was completed with R1. The agreement did not contain information on care, service, and payment provisions that would be provided to R1 while at the facility.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3