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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880902
Report Date: 09/12/2022
Date Signed: 09/12/2022 11:56:16 AM

Document Has Been Signed on 09/12/2022 11:56 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BUENA VISTA ASSISTED LIVINGFACILITY NUMBER:
331880902
ADMINISTRATOR:GRISELDA GARCIAFACILITY TYPE:
740
ADDRESS:1393 S. BUENA VISTA ST.TELEPHONE:
(951) 658-5160
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 49CENSUS: 35DATE:
09/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Griselda Torres-Garcia, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to conduct a case management health and safety visit in reference to repopulating the facility. LPA met with Administrator Griselda Torres-Garcia and explained the purpose of the visit. Ms. Torres-Garcia explained the facility evacuated Monday, 9/5/22, and repopulated on Saturday 9/10/22.

Thirty-Five (35) residents in care were present during the visit in the facility. 2 residents were still with family, but have plans to return today. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit.

An exit interview was conducted and a copy of this report was provided to Torres-Garcia.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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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