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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604274
Report Date: 12/07/2020
Date Signed: 12/07/2020 12:03:54 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: 72DATE:
12/07/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Jeff GonzalezTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Eva Torres conducted a virtual case management visit via FaceTime to follow up on two incidents that were reported by the facility on 12/04/20 and 12/07/20. LPA identified herself, spoke with Administrator, Jeff Gonzalez, and disclosed the purpose of the phone call.

During the call, LPA spoke with the administrator and obtained details of incidents, as well as requested records.

An exit interview was conducted with Administrator, Jeff Gonzalez, and the Licensee’s Rights (LIC9058 01/16) along with a copy of this report was provided to the administrator via email. A reply email or return receipt from the administrator will confirm receipt of documents.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica TorresTELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2020
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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