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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804037
Report Date: 01/23/2024
Date Signed: 01/23/2024 01:20:07 PM


Document Has Been Signed on 01/23/2024 01:20 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:VISTA HOMEFACILITY NUMBER:
486804037
ADMINISTRATOR:MEEHLEIB, MICHAEL CLARKFACILITY TYPE:
740
ADDRESS:2712 VISTA LINDATELEPHONE:
(650) 483-7269
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:4CENSUS: 4DATE:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:12 PM
MET WITH:Daryl Convento, LVNTIME COMPLETED:
01:45 PM
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01/23/2023 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Daryl Convento, LVN lead staff Gemma Posadas and explained the purpose of the visit. Administrator Michael Mephleib was unavailable for the visit.

LPA Knight and staff toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared. The facility has a hospice waiver for 3 residents.

Bedding, linens, and towels for residents were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the residents. Medication is locked in a cabinet.

The facility was observed to be at a comfortable temperature. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean, in good repair and contained necessary grab bars and non-slip floors. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational. No pools/bodies of water are on premises. No firearms are on premises.

LPA requested the following documents to be sent to CCL Santa Rosa office:
LIC 500- Personnel Report
Most up-to-date Liability insurance

In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report was provided to Daryl Convento,LVN.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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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