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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881741
Report Date: 06/27/2025
Date Signed: 06/27/2025 10:43:10 AM

Document Has Been Signed on 06/27/2025 10:43 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VISTA SENIOR LIVING II LLCFACILITY NUMBER:
371881741
ADMINISTRATOR/
DIRECTOR:		KAKANI, SHRIKANTFACILITY TYPE:
740
ADDRESS:247 PRESLEY PLTELEPHONE:
(619) 791-5495
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY: 15CENSUS: 5DATE:
06/27/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Shirkant Kakani, applicantTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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On 06/27/2025 Licensing Program Analyst (LPA) Javina George made an announced visit to the facility to conduct a pre-licensing inspection. LPA met with the Applicant, Shirkant Kakani, whom accompanied LPA throughout today's inspection. The applicant has applied for Change of Ownership with residents in care, and received an approved fire clearance from the Vista fire department on 03/21/25, for eight (8) non ambulatory and seven (7) bedridden residents. in addition the applicant has requested a hospice waiver for eight (8), residents.
LPA conducted an inspection and observed the following: The facility is a two structure story structure with 11 bedrooms 9 of which are for residents. The other (2) bedrooms are upstairs for staff use. Each resident bedroom has an exit door leading to the exterior of the property, and a bathroom. The bathrooms were observed to have walk in showers with non skid mats. The facility was observed to have a sprinkler system, with combined smoke and carbon monoxide detectors. The fire extinguishers are fully charged. The facility is equipped with solar panels as well as a Tesla charger with two (2) batteries. The medications, staff and resident files are stored inside the locked medication closet located in the hallway before entering into the dining room area. The sharps are stored in a locked cabinet underneath the sink. There are no pools or bodies of water on the premises. The hot water was checked and was found to be within regulatory limits. The facility was observed to be in possession of valid liability insurance that expires on 04/15/26.

The facility food supply was observed to be adequate as there is a 2 day supply of perishable and a 7 day supply of non-perishable foods. Facility has a first aid book and first aid supplies with the required items. Passageways were observed to be free of obstruction. There are activities for the residents such as puzzles, and games. Upon a review of the first aid kit no approved first aid manual, scissors or tweezers observed. The applicant purchased a new first aid kit during today's inspection. Component III was waived for the applicant Based on today's inspection the facility is ready for licensure. An exit interview was conducted and a copy of this report was reviewed and provided to Shirkant Kakani, applicant.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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