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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804037
Report Date: 12/15/2022
Date Signed: 12/15/2022 02:18:51 PM

Document Has Been Signed on 12/15/2022 02:18 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, 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: 4DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Lead Staff Member, Lourdes Soller TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Vista Home for the purpose of conducting a Required 1 year Inspection. LPA was greeted at the door by, Lead Staff Member, Lourdes Soller and was granted access into the facility.

LPA and Lead Staff Member toured the facility. 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. Fire Extinguisher was last serviced on November 2022. Living room fireplace is adequately screened and will not be used. Water temperature is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. LPA observed extra linens located in the closet. 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. Hazardous items were inaccessible to residents in care. Perishable and non-perishable foods observed per regulation. First Aid kit was inspected and found to be appropriate during the inspection. Carbon Monoxide detector and Smoke Detectors were inspected, tested and found to be operational during the inspection. Bathrooms contained necessary grab bars and non-slip floors. There was a supply of cleaners, hygiene products and paper products available for residents. Facility understands that resident’s beds must be outfitted with mattress pads as required by Title 22 Regulations # 87307.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored around the facility. Staff have had all PPE training required and have been N95 Fit tested, but not recertified.

LPA requested the following documents to be sent to CCL:

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VISTA HOME
FACILITY NUMBER: 486804037
VISIT DATE: 12/15/2022
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LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
LIC 610 (Emergency Disaster Plan)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of Residents

No deficiencies were observed or cited during the Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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