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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600544
Report Date: 05/23/2022
Date Signed: 05/23/2022 04:55:52 PM

Document Has Been Signed on 05/23/2022 04:55 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VINTAGE HOMEFACILITY NUMBER:
198600544
ADMINISTRATOR:LINDA WILLIAMSFACILITY TYPE:
735
ADDRESS:5418 N. FAIRVALLEYTELEPHONE:
(626) 502-1055
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 6DATE:
05/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Linda Williams, Administrator/ LicenseeTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Administrator, Linda Williams who assisted with the visit. The facility is licensed to serve six (6) ambulatory Developmentally Disabled clients who are ages 18-59. Current client census is six (6). None of the clients has a Restricted Health Condition. Six (6) clients residing at this home receive case management services provided by San Gabriel Pomona Regional Center. Annual licensing fees are current. LPA discussed the purpose of today's visit.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.



The facility is a single-family home located in a residential neighborhood and consist of three (3) client bedrooms, two (2) bathrooms, living room, kitchen, office area, dining area, laundry room, and outdoor activity area. Back yard activity area is a shaded area with chairs.

Bathrooms are clean and operable. Adequate linen and personal hygiene supply are in stock. Smoke detectors and carbon monoxide detector tested and operable. First aid kit is fully stocked. Hot water temperature measured at 108.2 degrees Fahrenheit. The last Fire/Emergency Drill was conducted on 04/1/22. Fire extinguishers are fully charged and last service was on 05/16/21.

Sufficient supply of perishable and non-perishable foods are observed. Medications are centrally stored, locked and the records are current.

(- Continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VINTAGE HOME
FACILITY NUMBER: 198600544
VISIT DATE: 05/23/2022
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Hazardous items are locked and inaccessible to clients. Administrator certificate is current and expires on 7/13/2022. Comfortable temperature of 75 degrees Fahrenheit for clients was maintained.

No deficiencies cited per California Code of Regulations, Title 22, Division 6.

Exit conference is conducted. LIC 809 is discussed and provided to Administrator, Linda Williams.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
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