374604274-9-27-2023-18-AS-JSRS-CW448U-20230927185318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604274
Report Date: 09/27/2023
Date Signed: 09/27/2023 06:53:24 PM

Document Has Been Signed on 09/27/2023 06:53 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 DEL LAGO MEMORY CARE		FACILITY NUMBER:	374604274
ADMINISTRATOR:	GONZALEZ, JEFF		FACILITY TYPE:	740
ADDRESS:	1817 AVENIDA DEL DIABLO		TELEPHONE:	(760) 741-2888
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92029
CAPACITY:	96	CENSUS: 91	DATE:	09/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Marie Hill, Executive Director		TIME COMPLETED:	06:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by Executive Director, Marie Hill. LPA began inspection with introduction and visit purpose. The facility services clients ages 60 and over, and is approved for 96 non-ambulatory clients of which 10 may be bedridden, hospice care waiver for 35 clients. There is an Infection Control Plan on file. This a full memory care facility. Smoke alarms and fire extinguishers were tested and remain operable. Drills are conducted regularly. The last drill was conducted on 9/23/2023. Client Records-Incident Reports/Clients Rights-Information/Dental- LPA reviewed client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/and Staffing- LPAs began review of employee records- Five (5) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen. (Continued on LIC809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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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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 DEL LAGO MEMORY CARE	FACILITY NUMBER: 374604274
	VISIT DATE: 09/27/2023

NARRATIVE

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Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 108.5 degrees F. Laundry is done in a large locked laundry room. There is a locked room for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained posted on the wall. There are no firearms at this facility. There is not a fireplace at this facility. There is not a pool at the facility. During the tour of the facility, LPA observed flooring damage in the hallway of the West wing roughly two and a half feet by 4 feet long. Laminate flooring appeared to be removed, and freshly cemented. LPA was informed that a water leak was discovered Thursday afternoon, repairs began Friday. LPA observed the damaged flooring area was marked off with safety tape and safety cones. LPA was informed they are fully staffed have had no client accidents throughout the repair process. Administrator states they are waiting on the cement to dry and final repairs should be completed by early next week. LPA took a photograph of the damaged flooring.

Medications- are centrally stored in two locked medication rooms located on the East and West side of the facility. There are locked cabinets allocated for medication storage. Centrally stored medication and destruction logs maintained separately.

Based on the information received during this visit today, there are zero (0) deficiencies observed per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted and a copy of this report was provided to Administrator, Marie Hill.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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