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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601228
Report Date: 09/13/2024
Date Signed: 04/14/2025 01:29:02 PM

Document Has Been Signed on 04/14/2025 01:29 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/
DIRECTOR:
ANNA WILSONFACILITY TYPE:
740
ADDRESS:625 MARAZON LANETELEPHONE:
(760) 295-0506
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY: 15CENSUS: 10DATE:
09/13/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:58 PM
MET WITH:ADMINISTRATOR, ANNA WILSONTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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On September 13, 2024, 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 introduced herself and explained the purpose of the visit.

LPA 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. Administrator informed LPA that all requirements for the Change of Ownership has been completed and the new application for the Emergency Approval to Operate (EAO), will be completed by close of business today. LPA discussed the documents required and the need to submit documents as soon as possible as the EAO has expired. Administrator provided copies of previous EAO's and email from CAB Analyst. Administrator informed LPA that the Fire Suppression System is being updated and waiting for approval from fire department.

LPA Mixson did not observe any health and/or safety hazards inside or outside of the facility at the time of this visit; LPA observed perimeter with a locked secured black iron gate with a sounding alarm when opened. LPA observed all facility utilities to be on and operating without issue. LPA observed bedrooms to have the required furnishings per regulations. LPA Mixson 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.

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

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Venus Mixson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
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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