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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005282
Report Date: 09/11/2024
Date Signed: 09/13/2024 10:31:21 AM

Document Has Been Signed on 09/13/2024 10:31 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VISTA HAVENFACILITY NUMBER:
397005282
ADMINISTRATOR/
DIRECTOR:		CHRISTINE QUIRUZFACILITY TYPE:
735
ADDRESS:758 FREWERT ROADTELEPHONE:
(209) 944-7752
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 5DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jasmyne Serrato and Christine QuiruzTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Unannounced Annual Licensing visit made out to this facility on 09/11/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Christine Quiruz, at this time. A brief interview was conducted with the facility designated Administrator at this time.
It was learned that this facility was vendorized to be able to accept and retain up to (6) Level 4I residents at any given time.
This facility is licensed to serve up to (6) Ambulatory only residents at any given time.
Current census was 5 residents, of which (4) of them, were out of the facility at their respectable day programs at this time. Tour of this facility was conducted.
A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time.
Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time.
A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.
Medication cabinet, located in the kitchen cabinet, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility designated staff members at this time. A review of the facility Medication Administration Record and dispensing log was conducted.
Medication cabinet was observed to be locked and made inaccessible to the residents at this time.
Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VISTA HAVEN
FACILITY NUMBER: 397005282
VISIT DATE: 09/11/2024
NARRATIVE
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A tour of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry area was toured. Cleaning supplies, detergents, and bleach were observed to be locked and made inaccessible to the residents at this time.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguishers were present and observed to be placed throughout this facility and were recently reviewed on 03/22/2024 by the local fire extinguisher company, Armor Fire Extinguisher, and observed to be in compliance at this time.
Administrator certificate for Christine Quiruz was observed to be present with certificate #6022150735 set to expire on 11/06/2024.

A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (5) facility resident files was conducted and noted on the following LIC 858.
A review of (5) facility staff files was conducted and noted on the following LIC 859.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were reviewed and a copy was printed and given to the facility designated Administrator at this time.
Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2024 10:31 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/11/2024 at 11:59 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VISTA HAVEN
FACILITY NUMBER: 397005282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that [2] out of [5] facility staff files did not contain updated first aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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The facility representative stated all facility staff will be updated and scheduled for first aid training to be current and certified at all times. A statement of correction, along with copies of updated first aid training, will be completed and submitted into CCL by the due date of 09/19/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


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