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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005282
Report Date: 11/06/2024
Date Signed: 11/12/2024 09:33:40 AM

Document Has Been Signed on 11/12/2024 09:33 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:
11/06/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Maria SerratoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Unannounced Plan of Correction visit made out to this facility on 11/06/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person Maria Serrato. A brief interview was conducted with the facility staff person at this time. This LPA requested that the facility staff person go ahead and contact the facility designated Administrator, Christine Quiruz, to inform her that CCL was present at this time.
Current census was 5 residents.
The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 09/11/2024. This visit was to follow up on the Plans of Correction that were due.
The following deficiencies were observed and cited on 09/11/2024:
  • 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 facility did complete the Plans of Correction and provided all of the required forms and documents at this time.

Plan of Correction clearance letters were printed and copies were provided to the facility staff person at this time.

There were no further deficiencies observed or cited during today's Plan of Correction visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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