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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600544
Report Date: 01/07/2025
Date Signed: 01/07/2025 01:12:40 PM

Document Has Been Signed on 01/07/2025 01:12 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/
DIRECTOR:		LINDA WILLIAMSFACILITY TYPE:
735
ADDRESS:5418 N. FAIRVALLEYTELEPHONE:
(626) 502-1055
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 5DATE:
01/07/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Linda Williams, administratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced initial case management visit regarding the death of client #1 (C1) which occurred on 12/10/24. LPA met with Administrator, Linda and explained the reason of the visit.

According to the death report dated 12/10/24, C1 deceased on 12/10/24 who was found death in bed in the morning by staff. The suspected cause of death was respiratory failure.

During today's visit, administrator was interviewed, C1's file was reviewed and obtained the following:
· Staff roster and Client roster
· Client #1 (C1) facesheet
· SOC 341, dated 12/10/24
· Death report, dated 12/10/24
· C1's IPP, dated 3/25/24.
· C1's last medical visit, dated 11/26/24
· C1's facility notes dated Jan 2024
· C1's Admission agreement,
· C1's MAR medication record Nov 2024.

Requested the following documents:
· C1's Police's Report and Death Certificate. Due on 1/14/25

Administrator stated she may get the death certificate and coroner report from C1's regional center (San Gabriel Pomona) when available. Exit interview was conducted and a copy of LIC 809 Report was provided to administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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