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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604474
Report Date: 01/24/2024
Date Signed: 01/24/2024 05:09:05 PM

Document Has Been Signed on 01/24/2024 05:09 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
SAN DIEGO RO, 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:
01/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Dominique John Mase, LicenseeTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Case Management visit to deliver an amended report for a visit conducted on 11/08/2023. LPA identified herself and was granted entry by Jolin Ly, caregiver. LPA met with Dominique John Mase, Licensee, and discussed the purpose of the visit.

During today’s visit, LPA obtained Licensee’s signature on the amended report LIC 809 dated (01/24/2024) and deficiencies were issued on the attached LIC809-D. Please note that Advisory Notes – Technical Assistance (LIC 9102TA) were issued in error.

An exit interview was conducted with Licensee Dominique Jonh Mase, to whom a copy of this report, the amended report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/24/2024 05:09 PM - It Cannot Be Edited


Created By: Carmen Lopez On 01/24/2024 at 03:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VISTA SERENO RCFE
FACILITY NUMBER: 374604474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2024
Section Cited
HSC
1569.695(e)

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H&S 1569.695 Emergency Plans (e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident… this requirement was not met as evidenced by:
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The facility did fill out a resident roster form after the initial visit on 11/08/23. LPA obtained a copy of the resident roster dated 11/08/23. This POC is deemed cleared.
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Based on records review, the facility did not have a Resident Roster on file for 3 of 3 residents [R1, R2, & R3]. This posed a potential safety risk to persons in care.
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Type B
02/07/2024
Section Cited
HSC1569.695(c)

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H&S Code Section 1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill… this requirement was not met as evidenced by:
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The fire drill form for the facility was filled out after the initial visit on 11/08/23 with one former fire drill they did not have on file for 10/2023 and a second fire drill conducted on 11/2023. LPA obtained a copy of the fire drill. This POC is deemed cleared.
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Based on records review, the facility did not have quarterly fire drills on file for the facility which posed a potential safety risk to 3 [R1, R2, and R3] of 3 persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Denise Powell
LICENSING EVALUATOR NAME:Carmen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
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