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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601158
Report Date: 11/04/2022
Date Signed: 11/04/2022 09:57:55 AM

Document Has Been Signed on 11/04/2022 09:57 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:VINTAGE HOUSEFACILITY NUMBER:
198601158
ADMINISTRATOR:KARLTON A. LEVIASFACILITY TYPE:
735
ADDRESS:717 SOUTH BRADFIELD STREETTELEPHONE:
(424) 338-6422
CITY:COMPTONSTATE: CAZIP CODE:
90221
CAPACITY: 4CENSUS: 4DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Karlton LeviasTIME COMPLETED:
10:30 AM
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On 11/04/2022, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA Scott was met by licensee Karlton Levias and the purpose of today’s visit was explained. The facility is licensed to serve four (4) developmentally disabled adults 18-59 years old. The facility fees are current.

There are currently 4 residents in care. There are 3 non-ambulatory and 1 ambulatory clients. The facility is a one-story structure with 2 bedrooms and 1 bathroom, living room, kitchen, and patio. Residents were at a day program at the time of this visit.

As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff and residents, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility has the mandated COVID infection control posters.

At 9:00 am, LPA Scott and Karlton Levias and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All resident rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. LPA observed the bathroom and found it to be within Title 22 regulations and were clean and operational. Water temperature measured 118.5 F.

Continued on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VINTAGE HOUSE
FACILITY NUMBER: 198601158
VISIT DATE: 11/04/2022
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LPA Scott observed the facility to be clean and appropriately furnished at the time of visit. LPA observed that cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available. Fire extinguisher was charged, smoke detectors and carbon monoxide were operable. Fire drill was last performed on 11/02/22.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA’s temperature was taken at the entrance of the facility and it was logged in the logbook for visitors.

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed under California code of regulation title 22, division 6, chapter 8.

Exit interview held and a copy of the report was provided to Administrator Karlton Levias

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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