374604274-9-23-2024-18-AS-SMAZ-D9DTJ3-20240923144539

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604274
Report Date: 09/23/2024
Date Signed: 09/23/2024 02:45:44 PM

Document Has Been Signed on 09/23/2024 02:45 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 CARE		FACILITY NUMBER:	374604274
ADMINISTRATOR:	MARIE HILL		FACILITY TYPE:	740
ADDRESS:	1817 AVENIDA DEL DIABLO		TELEPHONE:	(760) 741-2888
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92029
CAPACITY:	96	CENSUS: 95	DATE:	09/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Executive Director Marie Hill		TIME COMPLETED:	02:55 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) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Executive Director Marie Hill and Resident Service Director Priscilla Bermudas who was informed of the purpose of the visit. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies, detergents, and the sharp and dangerous objects were locked and inaccessible to the residents in the facility's janitorial and maintenance supply rooms. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector, carbon monoxide, and facility sprinkler system was operational and is maintained annually. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA was informed the facility receives multiple food deliveries a week. LPA reviewed four (4) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed, and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. The listed administrator possesses a current administrator's certificate.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 374604274
	VISIT DATE: 09/23/2024

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LPA observed medications are kept locked and inaccessible to residents in the medication room. LPA observed a MedTech getting ready to conduct blood glucose test for two (2) residents. Staff document medication administration on the facility's electronic Medication Administration Record (eMAR). LPA observed Medications prescribed to residents and found all medication listed on eMARS and all required labeling was found to be in place.

Facility has an updated emergency and disaster plan and Infection Control plan. LPA observed all facility exits were clear from obstructions. Facility has a working delayed egress system on the exit doors. LPA observed emergency supplies and first aid kit with all required items. Facility contained multiple charged fire extinguishers located throughout the facility. Facility conducts monthly disaster drills with the last drill being performed on 09/05/2024.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Executive Director Hill.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

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