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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920088
Report Date: 02/07/2025
Date Signed: 02/07/2025 03:45:30 PM

Document Has Been Signed on 02/07/2025 03:45 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VISTA ESPERANZAFACILITY NUMBER:
345920088
ADMINISTRATOR/
DIRECTOR:
VALENCIA, BRANDYFACILITY TYPE:
740
ADDRESS:5240 JACKSON STREETTELEPHONE:
(415) 590-0579
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 54CENSUS: 23DATE:
02/07/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Brandy ValenciaTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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On February 7, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received. LPA met with Administrator and explained the purpose of the visit.

The incident occurred on January 18, 2025, when night shift medication technician had marked a medication as given but it was later observed the medication was not administered. Administrator explained that S1 was in the middle of doing a medication pass when S1 was interrupted by another resident in care for assistance.

Administrator stated corrective actions were taken and S1 will be retraining on medication administration through Relias.

Administrator will submit S1's medication training to LPA Yang via email by February 14, 2025.

Exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
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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