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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604274
Report Date: 02/08/2023
Date Signed: 02/08/2023 12:36:31 PM


Document Has Been Signed on 02/08/2023 12:36 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: 92DATE:
02/08/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Executive Director, Jonathan ThomasTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct a health and safety check and case management visit concerning an incident report that was sent to the regional office on 2/7/2023 regarding R1. LPA met with Executive Director, Jonathan Thomas who was informed of the purpose of the visit.

LPA conducted a walk through of the facility. LPA observed the facility dining area was under going renovations, and observed the facility "bistros" which were being used for resident dining. LPA observed the residents medications were kept locked, and observed the facility utilities were operating properly. LPA observed the facility residents in the facility hallways, common area, and in their rooms.

LPA noted the current administrator was not the listed on facility profile. LPA advised the executive director to submit the proper documentation to the department.

No health or safety issues were observed during the time of the visit.

During the visit LPA collected documentation and conducted interviews. The Executive Director was advised of additional documents that would need to be sent to the LPA by Friday February 9,2023.

An exit interview was conducted with Executive Director, Jonathan Thomas, where this report was reviewed and provided to him.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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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