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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600544
Report Date: 06/15/2023
Date Signed: 06/15/2023 04:06:53 PM

Document Has Been Signed on 06/15/2023 04:06 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:
06/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Linda Williams, administratorTIME COMPLETED:
04:30 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. None of the clients has a Restricted Health Condition. All clients receive case management services provided by San Gabriel Pomona Regional Center. Annual licensing fees are current. LPA discussed with administrator of the purpose of today's visit.

During the visit, CARE tool was used, a tour of the facility was conducted, staff/clients files were reviewed, 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 a range from 107.2 to 114.5 degrees Fahrenheit which is in compliance with Title 22 regulation. The last Fire/Emergency Drill was conducted on 06/03/23. Fire extinguishers are fully charged. Administrator certificate is current which will expire on 7/14/24.

Sufficient supply of perishable and non-perishable foods are observed. Medications are centrally stored, locked and the records are current. Hazardous items are locked and inaccessible to clients. 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. Report LIC 809 is discussed and provided to Administrator, Linda Williams

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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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