198600544-4-5-2024-28-AS-KRAZ-D42LMB-20240405085224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600544
Report Date: 04/04/2024
Date Signed: 04/05/2024 08:52:49 AM

Document Has Been Signed on 04/05/2024 08:52 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	VINTAGE HOME		FACILITY NUMBER:	198600544
ADMINISTRATOR/ DIRECTOR:	LINDA WILLIAMS		FACILITY TYPE:	735
ADDRESS:	5418 N. FAIRVALLEY		TELEPHONE:	(626) 502-1055
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY: 6		CENSUS: 6	DATE:	04/04/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:22 AM
MET WITH:	Administrator Linda Willams		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

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Licensing Program Analysts (LPAs) Kimberly Ramirez and Christian Gutierrez conducted an unannounced subsequent required Annual Inspection visit on 04/04/2024. LPAs were met by Administrator Linda Williams and explained the purpose of the visit. The facility is licensed to serve six (6) ambulatory clients, ages 18-59 years old with developmentally disabilities. All clients at this facility receive services from San Gabriel/Pomona Regional Center.

LPA OBSERVATIONS: The facility is a single-story home that contains three (3) bedrooms, two (2) bathrooms, living room, kitchen, dining room, laundry area, backyard shaded patio area, and detached garage. LPAs observed four (4) staff providing care and supervision to two (2) clients out of six (6).

Front Yard: LPAs observed front yard to be free of hazards.

Kitchen: LPAs observed appliances to be clean and in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to two (2) out of six (6) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to two (2) out of six (6) clients in care.

Dining Room/Living room: Dining room was observed to contain one table with several chairs. The living room was observed to contain plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed one (1) client sitting in this area during inspection.

Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

See 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VINTAGE HOME	FACILITY NUMBER: 198600544
	VISIT DATE: 04/04/2024

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Client Rooms 1-3: LPAs observed all client bedrooms to contain the required linens, furnishings, and lighting. All client rooms are shared.

Bathroom 1-2: LPAs observed water temperature in these bathrooms to be within 105-120 degrees. LPAs observed non-slip mats in bathroom showers.

Backyard: No large bodies of water were observed.

Emergency Drills: Last documented disaster drill was conducted on 03/15/2024 and 02/13/2024.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPAs observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit. Fully charged fire extinguishers were observed throughout the facility.

Personnel Records: Personnel records are maintained at the facility. LPA Ramirez reviewed three (3) personnel records. First Aid Certificate, Fingerprint Clearance/ Exemptions, Personnel Record/Job Application, Health Screening, Employee Rights, TB Test, and Initial/Annual Training Verification. Administrator’s certificate for Linda Williams was observed with an expiration date of 07/14/2024.

Client Records: Client files are maintained at the facility. LPA Ramirez reviewed six (6) client records. No deficiency was observed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form.

Centrally Stored Medications- LPAs reviewed six (6) client medications. No deficiencies were identified.

Infection Control Plan: LPA Ramirez was unable to access infection control plan. Administrator will email Infection Control Plan to LPA Ramirez within 7 days.

No deficiencies were observed during inspection. Exit interview was conducted. A copy of this report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC809 (FAS) - (06/04)

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