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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604274
Report Date: 05/11/2022
Date Signed: 05/11/2022 12:10:35 PM


Document Has Been Signed on 05/11/2022 12:10 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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: 84DATE:
05/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Hilda Paz Sanchez, Community Relations DirectorTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced for the purpose of a complaint investigation (#, and met with Business Office Manager. During today's inspection, LPA George observed the following deficiency:

LPA George conducted interviews with multiple staff. LPA George reviewed the copy of the personnel roster obtained from the Licensing Information System (LIS) and observed that S1 and S2 were not associated to the facility. Deficiency cited.

To have an individual work at the facility without proper background clearance (or completion of transferring clearance) results in civil penalties in the amount of $100 per day, per individual.

LPA George will be issuing civil penalties in the maximum amount of $500 ($100 per day x 5 days) during today's inspection for both S1 and S2 totaling $1000.

LPA George conducted an exit interview with Hilda Paz Sanchez, Community Relations Director Hilda Paz-Sanchez, and a copy of this report, LIC809D, LIC421BG, and appeal rights were also provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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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Document Has Been Signed on 05/11/2022 12:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: VISTA DEL LAGO MEMORY CARE
FACILITY NUMBER: 374604274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited

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Criminal Record Clearance: (e) All individuals...shall prior to working, residing or volunteering in a licensed facility: (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement was not met as evidenced by:
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Based on observation and interviews, the Licensee did not comply with the above regulation with at least two staff (S1, S2). LPA George learned that S1 and S2 are not associated to this facility. This is an immediate safety risk to all residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
LIC809 (FAS) - (06/04)
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