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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203197
Report Date: 08/09/2023
Date Signed: 08/09/2023 09:23:21 PM


Document Has Been Signed on 08/09/2023 09:23 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:VINTAGE GARDENSFACILITY NUMBER:
107203197
ADMINISTRATOR:GEBBIA, LOUISFACILITY TYPE:
740
ADDRESS:540 S. PEACHTELEPHONE:
(559) 252-4036
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:158CENSUS: 64DATE:
08/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Louis Gebbia Administrator (Admin) Administrator & Sonja Hebler Wellness Director (WD) TIME COMPLETED:
09:45 PM
NARRATIVE
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An unannounced Annual visit was conducted on the date & time indicated above by Licensing Program Analyst (LPA) K. Kaur & LPA K. McClurg. LPAs met with Louis Gebbia Administrator (Admin) Administrator & Sonja Hebler Wellness Director (WD). LPAs introduced selves, stated purpose of visit & were allowed to proceed with visit.

Facility toured conducted. Hand sanitizer observed to available & accessible to residents and visitors throughout the facility. Sanitizer has not posed a risk to current residents. Facility appeared to be clean with no detectable unpleasant odors. Internal & external walkways & exits free of obstructions. Resident bathrooms appeared to be clean. Hot water measured @: (room # /degrees F): #214/126; #221/90; #234/90; #25/103; #140/105. Grab bars in all toilet & shower areas. Non-skid mats available in shower.

Cleanser containing Clorox observed on top of back of toilet area in Room #214. Comet powder & Comet spray cleanser observed under backroom sink in Room #234. Air freshener observed on top of cabinet over toilet in unlocked resident Room #25.

Additional cleansers observed in unlocked under counter cabinet to left of sink in Nikkei Education/Activity room.

Facility has multiple rooms for activities, as well as designated dining room. Rooms appeared to be well lighted & in good condition. Laundry facilities observed to be locked & sufficiently supplies. Beauty salon, Maintenance & other areas including storage observed to be locked. Smoke & carbon monoxide detectors observed throughout facility. Fire extinguisher service date: 4/26/2023.

(Continued)
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
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 6


Document Has Been Signed on 08/09/2023 09:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: VINTAGE GARDENS
FACILITY NUMBER: 107203197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 5 resident bathroom sinks which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2023
Plan of Correction
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Administrator agrees to submit a plan with details of how issue will be corrected, training provided, deadline will be completed by,& how will be maintained in future.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 5 resident bathrooms & 1 community room of general spaces toured which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2023
Plan of Correction
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Administrator agrees to submit a plan with details of how issue will be corrected, training provided, date facility will have all completed. Documentation of additional information will be maintained at facility.
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: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 08/09/2023 09:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: VINTAGE GARDENS
FACILITY NUMBER: 107203197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & record review, the licensee did not comply with the section cited above in 1 out of 2 medications which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2023
Plan of Correction
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Administrator agrees to submit a plan of how issue will be corrected, including complete medication audit, medication training, & process for documenting medication administration. Plan should include how will be maintained going forward. Plan will include the date all phases of plan will be complete.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 08/09/2023 09:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: VINTAGE GARDENS
FACILITY NUMBER: 107203197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(9)
General Food Service Requirements
(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Administrator agrees to provide training & have issue corrected & have plan for oversight/maintenance by due date.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & discussion with staff, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Administrator agrees that a 7 day supply of non-perishable & 2 day supply of perishable food will maintained on the premises @ all times, in addition to food supplies needed to serve meals & snacks between food delivery dates. Administrator agrees to have a summary of non-perishable food including total servings identified by proteins, vegetables, fruits, & grains.
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: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 08/09/2023 09:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: VINTAGE GARDENS
FACILITY NUMBER: 107203197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above in 1 out of 8 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Administrator agrees to be in process of working a plan to correct, including medication documentation reviews & audits, medication training, & date project will be completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: VINTAGE GARDENS
FACILITY NUMBER: 107203197
VISIT DATE: 08/09/2023
NARRATIVE
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Continued from page 1.

Kitchen food supplies & storage reviewed. Food observed uncovered &/or in open packages in refrigerator & freezer. Facility did not have 7-days of non-perishable food in addition to food for meals between food delivery dates on the premises. The 3-days (72 hours) emergency supply in accordance with Health & Safety ยง1569.695 Emergency Plans was included in 7-day supply of Non-perishable food.

Facility grounds appeared to be maintained with sufficient outside space & furnishings for outdoor activities.

Facility & resident records reviewed. Medications & medication records reviewed, including MARs & CSMDR. It was observed that a medication had more pills in bottle than it should have based on audit calculations. MARs for this medication indicated that it was given appropriately during calculated time period. Medication was also not included on CSMDR.


Deficiencies issued.

Exit interview conducted with Admin. Report & Appeal Rights provided at the time of visit.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6