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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600544
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:38:08 PM

Document Has Been Signed on 01/16/2025 02:38 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
GREATER LA AC/SC, 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: 6DATE:
01/16/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:04 PM
MET WITH:Linda WilliamsTIME VISIT/
INSPECTION COMPLETED:
02:39 PM
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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced case management visit regarding an incident on the relocation of 1 client from Bedell Family Crest 197601322 (Woodland Hills South RO) due to mandatory evacuation orders from the Fire Advisory. LPA met with Administrator, Linda Williams, and explained the reason for the visit.

During the visit today, LPA Lopez conducted a health and safety check, and no concerns were observed. LPA obtained a copy of the client and staff roster for Vintage Home 198600544. There were no rosters available for Bedell Family Crest (Woodland Hills South R) the last fire drill was conducted on 12/12/2024.

Per interview with the administrator, there is one (1) client that has been relocated from Bedell Family Crest 197601322 (Woodland Hills South RO). They have sufficient staffing to meet the needs of the clients. Food and hygiene supplies are available to accommodate a total of 6 clients. The facility has 3 bedrooms, 2 bathrooms, living room, dining area, and kitchen. The medications for the one (1) individual from Bedell Family Crest 197601322 (Woodland Hills RO) were transferred to the facility and are centrally stored and locked. Current facility created a new MAR as one was not sent with resident. All the clients in the facility are ambulatory and do not use any assisted devices. Administrator stated the families, responsible parties, and regional center for Bedell Family Crest 197601322 (Woodland Hills South RO) client have been notified of their relocation.

Administrator is now at capacity for six (6). LPA asked administrator to send incident report to Department regarding new client.

An exit interview was held, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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