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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604274
Report Date: 06/29/2022
Date Signed: 06/29/2022 12:35:31 PM


Document Has Been Signed on 06/29/2022 12:35 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,
, CA



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:
06/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Executive DIrector, Jeff GonzalesTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA), Kayla Hilario, conducted an unannounced case management visit to amend a report that was created on 02/02/2022. LPA identified herself, discussed the purpose of the visit and met

During the visit, LPA explained the amended 9099 page and obtained signature on the amended report. An exit interview was conducted with Executive Director Jeff Gonzales. The amended report, Licensee Rights (LIC 9058 01/16), and a copy of this report were provided to via hardcopy at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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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