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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801019
Report Date: 02/25/2022
Date Signed: 02/25/2022 01:25:44 PM


Document Has Been Signed on 02/25/2022 01:25 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:MOUNTAIN VISTA OF OJAIFACILITY NUMBER:
565801019
ADMINISTRATOR:NICKIE PEREZFACILITY TYPE:
740
ADDRESS:602 EAST OAK STREETTELEPHONE:
(805) 646-6850
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:38CENSUS: 29DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Nickie PerezTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Required 1 - Year visit to this facility. LPA met with Administrator Nickie Perez.

LPA conducted a facility tour to inspect for infection control practices. Infection control practices were discussed with the Administrator. An inspection of the common areas, resident rooms and restrooms were conducted. LPA observed hot water temperature at 105.1 and 110 degrees F. in resident bathrooms. LPA observed signal system which operates from each resident room. There is an adequate amount of perishable and non-perishable food. PPE supplies were observed. First Aid kit is complete. LPA observed the fire extinguishers fully charged. The smoke detectors and carbon monoxide detectors were tested and operable. LPA observed medications in locked medication carts and medication room. Outdoor area toured- passageways are free of obstruction.

No citations issued during today's visit.

Exit interview conducted, todays report was reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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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