<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610074
Report Date: 12/11/2023
Date Signed: 12/12/2023 08:12:17 AM

Document Has Been Signed on 12/12/2023 08:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VINTAGE HOME INC.FACILITY NUMBER:
197610074
ADMINISTRATOR:GALIZA, FILIPINASFACILITY TYPE:
735
ADDRESS:21048 VINTAGE STTELEPHONE:
(818) 700-9353
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 4CENSUS: 4DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:FILIPINAS GALIZA- Administrator TIME COMPLETED:
03:15 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) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with Administrator, Filipinas Galiza and explain the reason of the visit.
At approximately 10:15 am, with the assistance of staff, LPA took a tour of the physical plant.
The fire extinguisher is located in the kitchen. The charge date is December 11, 2023.
Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the staff kitchen. Properly labeled medications were locked in one of the staff kitchen cabinets. Smoke detectors/Carbon monoxide detectors are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested .Bedrooms: Facility has nine (9) bedrooms which of four (4) are designated for client use. LPA observed that two (2) out four (4) bedrooms appeared to have enormous amounts of personal belongings cluttering clients bedrooms. Bathrooms: Facility has 4.5 bathrooms. There are one and half (1.5) bathrooms designated for clients' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 103.6 and 116.2 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were properly furnished. Garage: There is an attached garage that is used for additional storage. Chemicals are stored in a lock cabinet in the garage. Outside Area: LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water. Laundry Area: located through the kitchen. Appliances observed to be in good repair. Laundry detergents are inaccessible to clients Medications: Medication and Medication Records were review for proper documentation.
LPA conducted a file review of clients and staff files to insure compliance.

Exit Interview Conducted, Deficiency Cited and a Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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 2
Document Has Been Signed on 12/12/2023 08:12 AM - It Cannot Be Edited


Created By: Mariana Agban On 12/11/2023 at 03:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VINTAGE HOME INC.
FACILITY NUMBER: 197610074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087

a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by
Deficient Practice Statement
1
2
3
4
 Based on observation licensee failed to ensure clients room are clean and free of clutter. This is a potential health and safety risk to clients in care.
POC Due Date: 12/26/2023
Plan of Correction
1
2
3
4
Administrator states will work with clients to ensure the rooms are clean and free of clutter. Administrator will send proof of correction.
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:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2