<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005282
Report Date: 08/30/2021
Date Signed: 08/30/2021 01:11:03 PM

Document Has Been Signed on 08/30/2021 01:11 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:VISTA HAVENFACILITY NUMBER:
397005282
ADMINISTRATOR:CHRISTINE QUIRUZFACILITY TYPE:
735
ADDRESS:758 FREWERT ROADTELEPHONE:
(209) 944-7752
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 5DATE:
08/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Maria Serrato, AdministratorTIME COMPLETED:
12:45 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
Licensing Program Analyst (LPAs) Arlene Garcia and Albert Johnson conducted an unannounced annual / Infection Control visit on this date. LPAs were greeted Maria Serrato, Caregiver S1, and met with Christine Quiruz, Administrator.

LPA and S1, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas.
LPA observed 2nd bathroom under construction and no hot water not coming out of sink.
LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 110 degrees in residents bathroom with the AD which is in required range of 105 to 120 degrees.

Last Fire Drill conduced dated 7/01/21. Fire extinguisher maintained 11/22//2020.
Fire alarm and carbon monoxide functional. LPA observed sharps and toxins locked.
LPA and AD observed centrally stored medications.

LPA reviewed 4 staff and 5 resident files. Resident emergency contact complete. LPA observed all staff files complete.
Administrator Certificate valid until 11/6/2022.

809 CONT. >>>>>>>>>>>>>>>>>>>>>>>>>>>>
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: VISTA HAVEN
FACILITY NUMBER: 397005282
VISIT DATE: 08/30/2021
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
26
27
28
29
30
31
32
809 CONT. >>>>>>>>>>>>>>

Staff and visitors enter the facility through ringing the locked front door, sanitizer and thermometer were observed. COVID signs posted in front entry way or throughout the facility. LPA observed masks and hand sanitizer available to visitors. Sign in sheets were observed to document date, visitors name, and temperature.

LPA reviewed 3 staff files and 5 resident files. While reviewing files, LPA observed all staff are vaccinated and have TB/Health Screen completed. All residents vaccinated. All residents files completed. All resident files have emergency contact information.

All persons in facility fully vaccinated. LPA observed residents wearing masks.
AD requested PPE supplies which LPA delivered at time of visit.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/30/2021 01:11 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 08/30/2021 at 11:18 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VISTA HAVEN
FACILITY NUMBER: 397005282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2021
Section Cited

1
2
3
4
5
6
7
80086 Alterations to Existing Building or New Facilities
(c) Prior to construction or alterations, state or local law requires that all facilities secure a building permit.
8
9
10
11
12
13
14
This requirement was not met based on evidence by LPA observed bathroom was under construction. LPa completed File review and not information was proivded to LPA regarding construction.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3