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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604321
Report Date: 07/22/2023
Date Signed: 07/22/2023 11:33:30 AM

Document Has Been Signed on 07/22/2023 11:33 AM - 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:SANTA FAUSTINA ARFFACILITY NUMBER:
374604321
ADMINISTRATOR:BEALS, SUSANFACILITY TYPE:
735
ADDRESS:227 BAVARIA DRTELEPHONE:
(760) 806-9616
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY: 6CENSUS: 5DATE:
07/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:ADMINISTRATOR, SUSAN BEALSTIME COMPLETED:
10:55 AM
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On July 22, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection. LPA Mixson met with Administrator, introduced self, and stated the purpose of the visit.

LPA Mixson toured the facility, along with the Administrator, and inspected the inside and outside of the facility. The facility is a single story building located at 227 Bavaria Dr. Vista, CA.
Physical Plant: The physical plant, is in good condition, neat, and orderly. Outdoor and indoor passageways are free of obstruction currently. The facility rooms have the required furniture and storage space, and sufficient lighting. All rooms were equipped with the required items as per regulations. The hot water temperature was tested and was within regulations. The three restrooms were equipped with liquid soap and paper towels. LPA Mixson toured the kitchen. The kitchen was clean, organized, and met required regulations. The facility shops for food weekly and/or as needed. All food requirements were met, the seven day supply of non perishables, and two day supply of perishable. The facility had activity schedules posted and available for review. LPA Mixson inspected the common areas. Smoke detectors were in the green, and Regional Center just completed the Title 17 inspections in June 2023. The fire extinguisher was in the green, and are sent to Fire hawk in March 2023. Carbon monoxide alarms, along with smoke detectors were observed. There was a locked and centralized storage area for medications. Medications are contained in bubble packs and are delivered by the pharmacy. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area.
CONTINUED ON 809-C
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SANTA FAUSTINA ARF
FACILITY NUMBER: 374604321
VISIT DATE: 07/22/2023
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 CONTINUED FROM 809

There was adequate seating in the common areas and sufficient space for activities. LPA Mixson observed menus posted in visible areas.

LPA Mixson reviewed four staff files, five resident files, and conducted three staff interviews and no resident interviews, due to residents being out in the community. There were no regulation violations observed during todays visit.

An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to Administrator
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2023
LIC809 (FAS) - (06/04)
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