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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604274
Report Date: 12/06/2024
Date Signed: 12/06/2024 03:23:23 PM

Document Has Been Signed on 12/06/2024 03:23 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VISTA DEL LAGO MEMORY CAREFACILITY NUMBER:
374604274
ADMINISTRATOR/
DIRECTOR:		MARIE HILLFACILITY TYPE:
740
ADDRESS:1817 AVENIDA DEL DIABLOTELEPHONE:
(760) 741-2888
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY: 96CENSUS: 90DATE:
12/06/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator, Marie HillTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 12/6/2024, Licensing Program Analyst (LPA), Janette Romero conducted an unannounced health and safety visit to the facility to follow up on an Unusual Incident/Injury Report (LIC 624) submitted by facility to the Department reporting an incident on 12/2/2024 involving Resident 1. LPA met with Administrator, Marie Hill who was informed of the purpose of the visit. LPA toured the facility, conducted interviews, and requested records. The requested documentation will be emailed to LPA by close of business on 12/9/2024.

During the tour, LPA observed the facility has working utilities along with a two-day supply of perishable food and seven-day supply of non-perishable food items. No deficiencies were cited during today's visit. No imminent health or safety concerns were observed. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Hill.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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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