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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804161
Report Date: 12/10/2024
Date Signed: 12/10/2024 10:40:54 AM

Document Has Been Signed on 12/10/2024 10:40 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VISTA PRADOFACILITY NUMBER:
486804161
ADMINISTRATOR/
DIRECTOR:		CHO, LINDAFACILITY TYPE:
740
ADDRESS:105 POWER DRIVETELEPHONE:
(707) 343-9352
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 68CENSUS: 42DATE:
12/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Veronica De-Leon ( Assisted Living Director)TIME VISIT/
INSPECTION COMPLETED:
10:55 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Cuadra and Stevenson conducted a case management visit to cite deficiencies discovered during a complaint investigation and met with Assisted Living Director, Veronica De Leon.

LPA learned through records review and interviews that facility staff did not submit incident reports to the Department after incident of resident (R1) had a bruise on their left eye. According to facility narrative charting the facility reached out to R1’s physician on 10/1/24 after noticing R1 had a discoloration on their left eye and next day there was an appointment for x-rays to be done. LPA was unable to find any incident reports made to the Department about this incident and no further details were documented regarding any investigation been conducted by the facility.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Assisted Living Director and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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Document Has Been Signed on 12/10/2024 10:40 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 12/10/2024 at 10:07 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VISTA PRADO
FACILITY NUMBER: 486804161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2024
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the events specified in (A) through (D) below: This requirement has not been met as evidence by:
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Facility to submit a plan of how facility will ensure future compliance regarding required written reports by POC date to clear the citation.
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Based on interview & records review the facility failed to submit written incident report to licensing agency for resident (R1) after noticing skin discoloration on their left eye, which possess potential health, safety, personal rights risk to clients in care.
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
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