397005282-9-26-2023-27-AS-APAA-CW33YP-20230926184017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005282
Report Date: 09/26/2023
Date Signed: 09/26/2023 06:40:28 PM

Document Has Been Signed on 09/26/2023 06:40 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 HAVEN		FACILITY NUMBER:	397005282
ADMINISTRATOR:	CHRISTINE QUIRUZ		FACILITY TYPE:	735
ADDRESS:	758 FREWERT ROAD		TELEPHONE:	(209) 944-7752
CITY:	LATHROP	STATE: CA	ZIP CODE:	95330
CAPACITY: 6		CENSUS: 6	DATE:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Christine Quiruz		TIME COMPLETED:	01:00 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 09/26/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by staff members, Robert Quiruz and Jasmine Serrato who stated that the Facility Designated Administrator was on their way. Shortly after, LPA met with Facility Designated Administrator, Christine Quiruz and House Manager, Mariafe Serrato and explained the purpose of the visit. Current Census was 6. 5 out 6 residents were out at their respective day programs at this time. This facility is licensed to serve and retain 6 ambulatory residents who are between the ages of 18 to 59. This facility is also vendorized by Valley Mountain Regional Center to serve and retain Level 4I residents at this time. The administrator has a current administrator certificate #6022150735 and expires on 11/06/2024. LPA reviewed 6 resident files and 5 staff files. A tour of the facility was conducted. 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 02/24/2023. 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.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VISTA HAVEN	FACILITY NUMBER: 397005282
	VISIT DATE: 09/26/2023

NARRATIVE

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A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time.
LPA Pascua observed a locked centralized stored medication cart located in the living room. Along with Administrator and House Manager, 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 610e

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: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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