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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203197
Report Date: 10/22/2021
Date Signed: 10/22/2021 12:45:39 PM

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: 58DATE:
10/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Executive Director, Louis GebbiaTIME COMPLETED:
11:43 AM
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Licensing Program Analyst (LPA) Darius Williams conducted a Case Management visit in response to report received on 10/18/2021, regarding Resident 1 falling and bumping their head. LPA Williams met with Executive Director, Louis Gebbia and discussed the purpose of the visit.

LPA Williams toured the facility and interviewed the Executive Director.

LPA Williams discussed the report and reporting procedures with the Executive Director.

No deficiency cited at this time.

An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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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