198601158-9-12-2024-11-AS-PSCT-D92PQB-20240912113052

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601158
Report Date: 09/12/2024
Date Signed: 09/12/2024 11:31:04 AM

Document Has Been Signed on 09/12/2024 11:31 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	VINTAGE HOUSE		FACILITY NUMBER:	198601158
ADMINISTRATOR/ DIRECTOR:	KARLTON A. LEVIAS		FACILITY TYPE:	735
ADDRESS:	717 SOUTH BRADFIELD STREET		TELEPHONE:	(424) 338-6422
CITY:	COMPTON	STATE: CA	ZIP CODE:	90221
CAPACITY: 4		CENSUS: 2	DATE:	09/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Shanda Griffin		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

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On 09/12/24, at 9:00am Licensing Program Analyst (LPA) Perry Scott conducted an unannounced visit to Vintage House. The purpose of today’s visit was to conduct the required annual inspection, using the new Care Tool. LPA was greeted by Trinece Levias, Manager, and Shanda Griffin, DSP, and the purpose of today’s visit was explained. The facility is licensed to serve for (4) ambulatory (Developmentally Disabled or Mentally Ill) adults ages 18 through 59. Currently, the home has (2) ambulatory clients. The clients are South Central Los Angeles Regional Center clients. None of the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The facilities annual fees are due on 09/18/24 for $202.00.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (2) client bedrooms (1) client bathroom, living room, kitchen, dining area, outdoor patio area, and a detached garage.

LPAs conducted a records review of (2) client records, (5) staff records, and reviewed the facility disaster plan. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (2) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

LPA and the DSP toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, adequate 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. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries available for clients. The water temperature measured at 114.5F. A comfortable temperature is maintained in the facility.

Report continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VINTAGE HOUSE	FACILITY NUMBER: 198601158
	VISIT DATE: 09/12/2024

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LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available, which is stored properly. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked with manual. Fire extinguisher was charged and last inspected on 6/09/2023. Smoke/ carbon Monoxide detectors were operable. The last fire/emergency drill was conducted on 09/10/2024.

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

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was held, and a copy of the Facility Evaluation Report was provided to Shanda Griffin, DSP.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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