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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201796
Report Date: 01/27/2022
Date Signed: 01/27/2022 05:22:51 PM

Document Has Been Signed on 01/27/2022 05:22 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:NUEVA VISTAFACILITY NUMBER:
435201796
ADMINISTRATOR:WEINSTEIN, MICHAELFACILITY TYPE:
735
ADDRESS:18225 HALE AVENUETELEPHONE:
(408) 465-8280
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 72CENSUS: 67DATE:
01/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:35 PM
MET WITH:Katie KnutsonTIME COMPLETED:
05:40 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Katie Knutson. During visit, LPA Marrufo spoke with Administrator Mark Castillo over the telephone. The visit was in response to a Death Report for resident R1 filed by the facility.

During the visit, LPA Marrufo interviewed Administrator Mark Castillo over the telephone and obtained the following documents for resident R1: Physician's Report, Appraisal/Needs and Services Plan, and Admission Agreement. LPA Marrufo requested Progress Notes for R1.

No deficiencies were cited at this time as per California Code of Regulations, Title 22.

This report was reviewed with Administrator Mark Castillo and Katie Knutson and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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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