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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203197
Report Date: 09/27/2024
Date Signed: 09/27/2024 01:08:12 PM


Document Has Been Signed on 09/27/2024 01:08 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
FRESNO RO, 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: 61DATE:
09/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Salvador De La Pena TIME COMPLETED:
01:15 PM
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On September 27 2024, Licensing Program Analyst, (LPA) Rachel Bruce arrived at the facility for the purpose of conducting an unannounced case management inspection. LPA was greeted and signed in at front desk. After explaining the purpose of the visit, the receptionist called Wellness Coordinator, Salvador De La Pena (SD) to assist. SD provided a tour of the facility. Everything appeared to be in order and no obvious issues were noted. LPA explained to SD the purpose of the visit and he explained that the Administrator was out ill due to COVID and the facility nurse was not present but on call. A phone call was made to the Administrator informing him of visit and he provided authorization for SD to sign the LIC 809 and provide any and all documentation requested.

Discussion was had with SD regarding recent incident reports submitted to CCL via fax on September 15, 2024. Four reports were received regarding the same client and all four reports were not submitted timely and lacked necessary information. SD reviewed the reports and provided supplemental information. LPA discussed regulatory requirements related to incident reporting and SD acknowledged his understanding. A review of the resident's file was conducted and documents copied. The resident involved was relocated to a six bed facility as of September 13, 2024 due to her need for increased care. Resident's husband remains placed at this facility.

Discussion of Incident Reporting also included details of when and why an incident report is required to be submitted. It was learned that three residents have tested positive for COVID and one is in the hospital None of these incidents had been reported as of today's date. SD will ensure that incident reports regarding COVID will be submitted for those who have tested positive and will continue to do so going forward.

LPA will return to the facility to meet with the Administrator next week to further discuss the facility's reporting protocol and to issue a citation at that time for failing to meet regulatory reporting requirements. LPA will call first to ensure that the Administrator is no longer testing positive for COVID.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Rachel A BruceTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
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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