107203197-7-5-2024-24-AS-LPAT-D6VV78-20240705161043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107203197
Report Date: 07/05/2024
Date Signed: 07/05/2024 04:13:57 PM

Document Has Been Signed on 07/05/2024 04:13 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 GARDENS		FACILITY NUMBER:	107203197
ADMINISTRATOR:	GEBBIA, LOUIS		FACILITY TYPE:	740
ADDRESS:	540 S. PEACH		TELEPHONE:	(559) 252-4036
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	158	CENSUS: 62	DATE:	07/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Koreena Kirkendall, Wellness Coordinator		TIME COMPLETED:	01:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA introduced herself and explained the purpose of the visit. Administrator was unavailable to met with LPA. LPA met with and toured the Facility with Wellness Coordinator, Koreena Kirkendall. During this visit, LPA toured the facility and grounds. LPA observed residents participating in activities. This facility has 2 floors with Resident rooms and a basement level floor with activity center, kitchen and dining. Ambient temperature was 72 degrees F. LPA entered 6 resident bedrooms. LPA observed rooms were appropriately furnished. Bathrooms contained grab bars in shower and around toilet, non skid mat in showers, shower chair, trash can with lid. Windows and screens in good condition. Water temperature was observed as follows: Room #120 at 130.3, Room #127 129.4 Room #238 at 129.0, Room #219 at 129.4 Room #208 at 100.6. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives are stored appropriately. Refrigerator was observed to be at 42 degrees F and Freezer at 0 degrees F. LPA observed 2 day perishable and 7 day non perishable food supply available. No expired food observed. Dining area has daily menu posted. Tables and chairs appeared clean in good condition. Medications are centrally stored in locked room. Med Carts are used by Med Tech when distributing medications. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kit found to contain required items.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

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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Document Has Been Signed on 07/05/2024 04:13 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: VINTAGE GARDENS	FACILITY NUMBER: 107203197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/05/2024

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
1 2 3 4	Based on LPA observation of water temperatures measured in 6 resident bathroom sinks, 4 of 6 were above 120 degrees and 1 of 6 was below 105 degrees. The licensee did not comply with the section cited above in 5 out of 6 resident bathroom sinks which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/08/2024
	Plan of Correction
1 2 3 4	Maintence was notified during this inspection. Water will be brought into compliance by the due date. Licensee will provide Licensing Dept with verification that the water temperature has been corrected as well their plan for monitoring water temperature going forward.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: VINTAGE GARDENS	FACILITY NUMBER: 107203197
	VISIT DATE: 07/05/2024

NARRATIVE

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Rear Patio area is well maintained, trees, bushes and yard decorations are in good condition. There is a seating areas with umbrellas or shaded by trees. Patio furniture is clean and ready for use. The exterior walkways are free from obstructions and debris.

Maintenance room observed to contained tools and supplies.

Fire Extinguishers are located throughout the facility and were serviced in on 5/21/2024. Smoke and Carbon Monoxide detectors observed. Fire inspection completed by Jorgensen on 9/18/2023 and received passing grade.

LPA conducted resident and staff file reviews.

An exit interview was conducted with Koreena Kirkendall, whose signature on this form confirms receipt of these documents.

LPA is requesting the following documents be submitted to the Fresno CCL office by 7/12/24 Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610D) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond, updated facility sketch.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

LIC809 (FAS) - (06/04)

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