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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005282
Report Date: 08/10/2022
Date Signed: 08/10/2022 02:49:27 PM

Document Has Been Signed on 08/10/2022 02:49 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: 4DATE:
08/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Christine QuiruzTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Arielle Pascua conducted an unannounced required-1 year inspection visit on 08/10/2022. LPA Pascua was greeted by staff member, Reginald Sampablo who was asked to call the administrator to let them know that CCL was present at this time. Shortly after, LPA Pascua met with Facility Designated Administrator, Christine Quiruz and stated the purpose of today's visit. There were two other staff members present, Maria Serrato and Robert Quiruz. Administrator holds a current certificate and expires on 11/06/2022.
This facility is vendorized by Valley Mountain Regional Center to accept and retain Level 4I residents at this time. Census was currently at 4. Tour of the facility was conducted with Facility Designated Administrator, Christine Quiruz and House Manager, Maria Serrato.
The facility has a main entrance screening point. The facility has a 30 day supply of PPE. The facility conducts disinfecting cleaning daily.
The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Armor Fire Extinguisher Company 01/11/2022.
The kitchen area was toured. LPA observed a sufficient seven days of non-perishable foods as well as two days worth of perishable food supplies in the main kitchen. Additional perishable and non-perishable food supplies were identified out in the back patio.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.
A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.
A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of the staff bedroom was also conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2022
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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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: 08/10/2022
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LPA Pascua observed a locked centralized stored medication cart located in the staff room. Along with Administrator, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components.
The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.
Exit interview.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC809 (FAS) - (06/04)
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