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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804037
Report Date: 02/03/2022
Date Signed: 02/03/2022 10:59:25 AM

Document Has Been Signed on 02/03/2022 10:59 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VISTA HOMEFACILITY NUMBER:
486804037
ADMINISTRATOR:MEEHLEIB, MICHAEL CLARKFACILITY TYPE:
740
ADDRESS:2712 VISTA LINDATELEPHONE:
(650) 483-7269
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 0DATE:
02/03/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Licensee, Melissa LipardoTIME COMPLETED:
11:10 AM
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Licensing Program Analysts (LPAs) Willis and Felias arrived announced to conduct a Pre-Licensing Inspection and met with Licensee Melissa Lipardo.

Upon arrival, LPAs observed Covid-19 posters on the front door. Once inside, LPAs observed multiple Covid-19 posters and a screening station for Covid-19 symptoms that included masks, hand sanitizer, sanitizing wipes, and a thermometer. Facility is a one story residence with four single client bedrooms, two bathrooms and common areas. All client rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Bathroom shower has non-skid shower floor and grab bars. Living room fireplace is adequately screened and will not be used. Water temperature in bathrooms read at 110 and 113 degrees F which are within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Facility has a locked cabinet in the hallway used for centrally stored medications and files. Cleaning supplies and toxins will be locked in a cabinet in the garage. Perishable and non-perishable foods observed per regulation. Facility backyard has multiple areas for visiting and activities. LPAs observed the backyard is tiered which may pose a risk to residents in care. Ways to make area safer will be discussed with Licensee and LPM.

Facility received an approved fire clearance dated January 4, 2022 that allows for four non-ambulatory clients. Facility has emergency lighting in hallways. LPAs confirmed that contents of the facility First Aid Kit were sufficient and that facility has emergency lighting in case of a power outage.

LPAs confirmed that Applicant is familiar with Guardian and has read the most recent Provider Information Notices (PINs) that the department sent out regarding Covid-19 vaccinations and visitation.

Component III is waived due to Applicant being a current Licensee.

Once concerns with backyard are remedied, LPAs will notify Application Unit so application process may proceed.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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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