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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804037
Report Date: 02/13/2025
Date Signed: 02/13/2025 03:56:15 PM

Document Has Been Signed on 02/13/2025 03:56 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/
DIRECTOR:		HEZLE LOMIBAOFACILITY TYPE:
740
ADDRESS:2712 VISTA LINDATELEPHONE:
(650) 483-7269
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 4DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Melissa Lipardo, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analysts (LPA)’s Shannan Hansen & Ethel Contreras arrived unannounced to conduct a required Annual inspection and was greeted by LVN Daryl C. Licensee, Melissa Lipardo arrived later for Administrator who was unable to attend. Facility has 4 residents with a fire clearance for 4 Non Ambulatory of which 1 may be bedridden (RM 3). Facility has a Hospice Waiver for three although does not have any residents/clients currently on hospice. There is 1 resident/client with a diagnosis of dementia.

At approximately 11:35 am LPA’s and staff toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. At aprox 11:41am LPA’s observed kitchen cabinet containing cleaning supplies and sharp knives unlocked, although staff was present in dining room.



All bedrooms were equipped with lighting/lamp, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required slip resistant mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 114.9 to 119.8 degrees F, within the allowable range of 105 to 120 degrees F. Facility understands that resident’s beds must be outfitted with mattress pads as required by Title 22 Regulations # 87307.

Fire extinguishers were last charged 9/5/2024. Smoke/Carbon Monoxide combination detectors located throughout the facility are connected to ADT and tested monthly on log. Exit doors have an auditory alert system that was functional at time of inspection. Facility’s last quarterly disaster drill was conducted on 2/1/2025. Licensee indicated facility is purchasing backup generator for use during a power outage.

At approximately 12:30 pm on 2/13/2025 LPA’s conducted a review of four resident files and learned that 4 of 4 residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A).
Continued on 809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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: 02/13/2025
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At approximately 1:00 pm on 2/13/2025 LPA conducted a review of five out of seventeen staff files and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements are current and LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed, although there was a discrepancy with some 1st Aid. (TA).

At approximately 12:45 pm LPA’s and LVN conducted a spot check of medication and medication records. No discrepancies observed. Medication is centrally stored in a locked closet in the hallway. P&I monies documented, secured and not commingled.

Hezle Lomiboa Administrator Certificate 6065313735 expires 6/9/2025. All fees are current. LPA’s and Licensee discussed facility's Infection Control Plan and Emergency Disaster plan.

Exit interview conducted & copy of report left

No deficiencies cited during today's inspection

LPA Hansen has requested the following documents updated and submitted to CCL by 2/27/2025.
LIC500- Personnel Report
LIC308- Designation of Responsibility (if changes)
LIC400 Cash Resources
LIC402 Surety Bond
LIC9020 Register of Facility Residents
Emergency Disaster Plan (if changed)
Copy of Current Liability Insurance
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
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