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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604274
Report Date: 10/21/2022
Date Signed: 10/21/2022 12:59:56 PM


Document Has Been Signed on 10/21/2022 12:59 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: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: 94DATE:
10/21/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Executive Director, Levina DuboseTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility in order to conduct a health and safety check. LPA met with executive director, Levina Dubose who was informed of the purpose of the visit.

At the time of the visit were (97) residents present. LPA conducted a walk through of the facility and observed the residents, staff, and stock of supplies at the facility. LPA walk through the facility kitchen. LPA was shown the facility's 7-day non-perishable supply and 2-day perishable food supply. LPA observed the facility's incontinent supply in the facility nursing closet. LPA walked through the west wing and east wing of the facility of the facility and observed residents in the common areas sitting on couches, in their bedrooms, and in activity rooms. LPA observed resident medications in secured nursing stations on the west wing and east wing. LPA observed and took pictures of water station on both the east wing and west wing of the facility. LPA observed the facility's 30 day supply of PPE equipment that is being stored in the staff lounge. LPA observed cleaning staff cleaning residents rooms.

LPA requested a copy of the resident roster and well as the staff roster. LPA checked staff listed for background check clearances.

No health and safety issues were noted during the time of the visit. No deficiencies were issued at the time of the visit.

An exit interview was conducted where a copy of this report was reviewed and provided to Executive Director, Levina Dubose.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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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