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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601228
Report Date: 12/29/2023
Date Signed: 12/29/2023 12:24:40 PM

Document Has Been Signed on 12/29/2023 12:24 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ALTA VISTA MANORFACILITY NUMBER:
374601228
ADMINISTRATOR:ANNA WILSONFACILITY TYPE:
740
ADDRESS:625 MARAZON LANETELEPHONE:
(760) 295-0506
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY: 15CENSUS: 8DATE:
12/29/2023
TYPE OF VISIT:Case Management - Health ChecksANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:ADMINISTRATOR, ANNA WILSONTIME COMPLETED:
12:28 PM
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On December 29, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a case management health and safety visit, and met with the Administrator, Anna Wilson. LPA Mixson introduced herself and explained the purpose of the visit.

LPA Mixson toured the facility, along with the Administrator and made observations and requested and received pertinent documents. There are no imminent health and/or safety concerns observed at the time of visit.

LPA Mixson did not observed any health and/or safety hazards inside or outside of the facility at the time of this visit. LPA observed all facility utilities to be on and operating without issue. The LPA assessed the available food supply and observed there was a variety of food types, and the supply exceeds the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. The medications were found to be in sufficient supply, locked, and inaccessible to the residents and are delivered by Quality Care Pharmacy.

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 observed or cited during today's visit.

An exit interview was conducted and a copy of this report was provided to the Administrator, Anna Wilson.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2023
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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