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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804037
Report Date: 03/14/2023
Date Signed: 03/14/2023 03:22:03 PM

Document Has Been Signed on 03/14/2023 03:22 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:
03/14/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Caregiver, Liza DaahlenTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Vista Home for the purpose of conducting a Case Management-Licensee Initiated inspection. LPA was greeted at the door by Caregiver, Liza Daahlen, and was granted access into the facility. Based on the STD 850, facility was approved for 3 Non-Ambulatory residents and 1 bedridden resident on February 22, 2023 and approved by the Fairfield Fire Department. LPA reviewed the STD 850 and the facility sketch and confirmed bedroom #3 was the room that was approved for a bedridden resident.

LPA and Caregiver toured the facility. Facility is a one story residence with four single resident bedrooms, two bathrooms and common areas. All resident rooms including bedroom #3 are appropriately furnished per regulation with a bed, lamp, dresser, chair and bedside table. Facility is clean and at a comfortable temperature with all exits free from obstruction.

No deficiencies were observed or cited during the Case Management-Licensee Initiated inspection. Exit interview was conducted and a copy of this report was given to the Caregiver.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023
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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