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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604274
Report Date: 08/25/2020
Date Signed: 08/25/2020 12:24:53 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:VISTA DEL LAGO MEMORY CAREFACILITY NUMBER:
374604274
ADMINISTRATOR:GONZALEZ, JEFFFACILITY TYPE:
740
ADDRESS:1817 AVENIDA DEL DIABLOTELEPHONE:
(760) 741-2888
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:96CENSUS: 87DATE:
08/25/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director, Jeff GonzalezTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Eva Torres conducted a virtual visit via FaceTime to perform the Pre-licensing inspection, due to COVID-19. LPA identified herself and spoke with Executive Director, Jeff Gonzalez. The purpose of today’s virtual inspection is to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. Facility is approved to serve ninety-six (96) elderly residents, in which ten (10) residents may be bedridden.

During the inspection, the Executive Director briefly provided a virtual tour of the facility. LPA observed the facility to be clean, and in good repair with no pathway obstruction. The resident's bedrooms, shower rooms and common areas were inspected and found to be in compliance. All required postings were posted in the front lobby. There were sufficient food supply observed. Administrator Certificate expires on 11/20/21. The facility does not have firearm and/or ammunition on grounds.

CCLD has completed the virtual Pre-licensing inspection, Comp III was provided. CCLD management was informed of the findings of the inspection. Final review and approval is pending with the Application Bureau.

An exit interview was conducted with Executive Director, Jeff Gonzalez and the Licensee’s Rights (LIC9058 01/15) along with a copy of this report was provided to the Executive Director via email. A reply email or return receipt from the Executive Director will confirm receipt of documents.

SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Evangelica TorresTELEPHONE: (619) 990-1407
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020
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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