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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603415
Report Date: 01/07/2023
Date Signed: 01/07/2023 12:01:34 PM

Document Has Been Signed on 01/07/2023 12:01 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 HOME IIFACILITY NUMBER:
198603415
ADMINISTRATOR:WILLIAMS, LINDAFACILITY TYPE:
735
ADDRESS:209 S. MOCKINGBIRD LNTELEPHONE:
(626) 638-8161
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
01/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:DSP, Ngozi Williams-OnwusoTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was met and screened for covid upon entry into this home by Ngozi Williams-Onwuso, Direct Support Professional/DSP. LPA explained the purpose of today's visit. The facility is approved for 4 Developmentally Disabled Adults, ages 18-59 and ambulatory only. There are current 4 ambulatory clients residing at the home. At 10:45a.m., Administrator Linda Williams arrived and assisted LPA with the inspection. This single-story home contains three (3) bedrooms, two (2) bathrooms, a living room, kitchen, dining area, office area, backyard, and detached garage.
The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet.
  • COVID-19 signage was placed in several areas of the facility.
  • Facility maintained a 30-day supply of PPE located in the supply closet inside the home and garage.
  • Both staff on duty wore face masks.
  • The kitchen was inspected. There were sufficient supplies of 2-day perishables and 7-day non-perishable foods. All the appliances are clean and working properly.
  • Cleaning solutions and kitchen knives/sharps were locked and stored in the storage/supply room and inaccessible to clients.
  • Hot water temperature was measured in kitchen and bathrooms. Kitchen read at 113.2 deg F, bathroom #1 read at 116.4 degrees F and bathroom #2 read at 115.9 deg F. The hot water readings were within the required 105 - 120 degrees.
  • Clients bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space.
  • Bathrooms have the required grabs bars, non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper.
  • Medications were locked, centrally stored, and given as prescribed. Medications were reviewed for all (4) clients and facility maintained a 30-day supply of medications.
  • Clients' medications were reviewed to confirm medication is given as prescribed and is documented properly.
  • The common areas such as living room and dining room are clean and have the required furniture. Furniture and group activities were spaced to encourage physical distancing.
  • The backyard does not have a shaded area but chairs and table are provided for clients and visitors. It has been designated as the visitor area for COVID-19 pandemic.
  • There is a fire extinguisher in the dining room and was observed to be fully charged and last serviced on September 2022.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • The laundry room is located outside and has cleaning supplies inaccessible to residents.
  • Staff and Clients files were not reviewed during this visit.

Deficiency was cited, exit interview conducted, and copy of the report and appeals rights were provided to the Administrator, Linda WIlliams.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2023
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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Document Has Been Signed on 01/07/2023 12:01 PM - It Cannot Be Edited


Created By: Bennette Pena On 01/07/2023 at 11:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VINTAGE HOME II
FACILITY NUMBER: 198603415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the Administrator did not comply with the section cited above in which the LPA observed that the backyard did not provide a shaded area for clients and visitors which posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 01/13/2023
Plan of Correction
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Administrator will send photos and receipts of purchase of the patio furnitures with umbrella to LPA on or before the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2023


LIC809 (FAS) - (06/04)
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