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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603317
Report Date: 05/11/2022
Date Signed: 05/13/2022 08:39:57 AM

Document Has Been Signed on 05/13/2022 08:39 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VINE RESIDENCEFACILITY NUMBER:
198603317
ADMINISTRATOR:LOPEZ, LORRAINEFACILITY TYPE:
740
ADDRESS:1405 E. VINE AVETELEPHONE:
(626) 890-7634
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 6DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Lorraine Lopez-Administrator TIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with Staff Gracie Martinez and explained the reason for the visit. Shortly after, the administrator Lorraine Lopez arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files.

The facility is licensed for 6 residents with ambulatory, of which 5 maybe non-ambulatory and 1 maybe bedridden, hospice wavier for 4. The facility is a single story house and located in a residential area. The facility consists of : living room, dining room, kitchen, TV room, 5 residents' bedroom, 2 residents' bathrooms, 1 staff room and 1 staff bathroom and a attached garage. Bedroom#1-#4 have one bed, one chair, one night stand, one drawer and required bedding and furniture and sufficient lighting and closet space. Bedroom#5 has two beds, two chairs, drawer, night stand, required bedding and furniture and sufficient lighting and closet space. All 2 residents bathroom were toured and they are clean, sanitary and operational. Both bathrooms have the required grabs bars and non-skid mats. The hot water in both resident bathrooms were measured between 112.1 and 112.6 which is within Title 22 regulation.
The refrigerator, kitchen cabinet and garage has sufficient two days perishable and seven days non-perishable food. All the appliances are clean and working properly. The sharp knives and utensils are stored and locked in the lock box. All the toxic and cleaning supplies are stored and locked in the cabinet in the garage which is inaccessible with residents. The common areas such as living room, dining room and TV room are clean and have the required furniture. The front and back yard are maintained well. The back yard has a shaded area with table and chairs and is available for residents to use. The facility has a swimming pool and it is fenced and in compliance with state and local building codes The exit and passage way are free of obstruction.

See LIC 809C for continuation
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VINE RESIDENCE
FACILITY NUMBER: 198603317
VISIT DATE: 05/11/2022
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LPA reviewed all 6 residents files to confirm emergency contact and they are all updated in the file. LPA also reviewed 2 staff files to confirm health screenings and fingerprint clearances and both staff has health screening forms on file and they are all fingerprint cleared. LPA reviewed 6 residents medication and all the medications are centrally stored and locked in the hallway cabinet and they are all current and updated.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in each common area and residents' rooms, and facility is disinfected every shift, residents' bathrooms have sufficient soap, paper towels, and signs, and PPE supplies are sufficient for more than 30 days.

No deficiencies were found during this visit. Exit interview was conducted with Administrator Lorraine Lopez and a copy of this report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC809 (FAS) - (06/04)
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