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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604474
Report Date: 01/10/2024
Date Signed: 01/10/2024 03:14:19 PM

Document Has Been Signed on 01/10/2024 03:14 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:VISTA SERENO RCFEFACILITY NUMBER:
374604474
ADMINISTRATOR:MASE, DOMINIQUEFACILITY TYPE:
740
ADDRESS:2725 VISTA SERENO CT.TELEPHONE:
(619) 405-3586
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY: 4CENSUS: 3DATE:
01/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Caregiver Jolin Ly and Administrator Dominique MaseTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Dang Nguyen and Juliana Barfield conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Jolin Ly. LPAs also met and spoke with Administrator Dominique Mase, who arrived later during the visit.

Today's visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 01/09/2024. [See LIC 811 Confidential Names List for a description of C1]. Per the report, R1 passed away on 01/05/2024.

During today’s visit, LPAs performed a brief facility tour and welfare check on remaining clients, finding no safety concerns. LPA also collected copies of and reviewed pertinent records and interviewed relevant staff.

No deficiencies were cited during today’s visit. However, one (1) Technical Violation was issued regarding Maintenance and Operation (see the LIC9102-TV).

An exit interview was conducted with Ly. A copy of this report, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to the Licensee during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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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