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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604274
Report Date: 11/18/2020
Date Signed: 11/23/2020 05:17:31 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: 89DATE:
11/18/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jeff Gonzalez, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Regional Manager (RM), Icela Estrada; Licensing Program Manager, Denise Powell, County of San Diego Nurse Contractors, Robert Montillano, and Jennifer West; California Department Public Health (CDPH), Health Facility Evaluator Nurses (HFEN), Denise Elliott and Hosinyeh Bagheri with the HAI Program, conducted an on-site visit. RM and team identified themselves and discussed the purpose of the visit with Administrator, Jeff Gonzalez and Resident Services Director Lavina Dubose.

The Department conducted a secondary on-site visit to go over the recommendations and to provide additional technical assistance. Today the team evaluated the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment. During today's visit, the team interviewed Administrator Gonzalez and conducted a walk-through of the facility. During the walk-through, the team observed staff interacting with the residents and using PPE. The HAI team inspected stock of PPE and sanitizing supplies. A debriefing was conducted with the administrator at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with the Administrator and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to him via electronic mail. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Denise PowellTELEPHONE: 619-301-9770
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020
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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