374604512-7-22-2023-18-AS-VMIN-CTYS5H-20230722133422

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604512
Report Date: 07/22/2023
Date Signed: 07/22/2023 01:34:28 PM

Document Has Been Signed on 07/22/2023 01:34 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 VILLAGE CARE		FACILITY NUMBER:	374604512
ADMINISTRATOR:	MILOSAVLJEVIC, MILIJANA		FACILITY TYPE:	740
ADDRESS:	222 WASHINGTON STREET		TELEPHONE:	(760) 518-5061
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	12	CENSUS: 9	DATE:	07/22/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:08 AM
MET WITH:	LEAD CAREGIVER, AIDEE SANTIAGO		TIME COMPLETED:	01:45 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	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 Lead Caregiver, Aidee Santiago, introduced self, and stated the purpose of the visit. LPA Mixson toured the facility and inspected the inside and outside of the facility. The facility is a single story building located at 222 Washington St. Vista Ca. 92084. Physical Plant: The physical plant is clean, neat, and orderly. Outdoor and indoor passageways are free of obstruction at the time of the inspection. The facility has eight bedrooms, and each room has the required furniture and storage space, and sufficient lighting. All rooms were equipped with the required items as per Title 22 regulations. The hot water temperature was tested and was within regulations. The seven restrooms were equipped with liquid soap and paper towels. The LPA toured the kitchen, living room and the TV room. The kitchen area was clean, organized, and free or odors. The facility grocery shops for food weekly and as needed. All food requirements were met, the seven day supply of non perishables, and two day supply of perishable. The LPA inspected the common areas, and the laundry room. Smoke detectors were in the green and operable. The fire extinguisher was in the green, and last reviewed for services in XXXXXX. Carbon monoxide alarms, along with smoke detectors were observed. CONTINUED ON 809-C

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
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: VISTA VILLAGE CARE	FACILITY NUMBER: 374604512
	VISIT DATE: 07/22/2023

NARRATIVE

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CONTINUED FROM 809
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. There was adequate seating in the common areas and sufficient space for family visitors. LPA Mixson observed menus posted in visible areas.

LPA Mixson reviewed four staff files, five resident files, and conducted three staff interviews and five resident interviews. There were no Title 22, Division 6 Regulation violations observed and/or cited during todays visit.

An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to the Lead Care Giver.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
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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