198603415-12-19-2023-28-AS-CWOG-CYNSR5-20231219130547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603415
Report Date: 12/19/2023
Date Signed: 12/19/2023 01:06:26 PM

Document Has Been Signed on 12/19/2023 01:06 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 II		FACILITY NUMBER:	198603415
ADMINISTRATOR:	WILLIAMS, LINDA		FACILITY TYPE:	735
ADDRESS:	209 S. MOCKINGBIRD LN		TELEPHONE:	(626) 638-8161
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 4		CENSUS: 4	DATE:	12/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Nikechi Alozie		TIME COMPLETED:	01:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP Nikechi Alozie and explained the reason of the visit. Shortly after, the administrator Linda Williams arrived and assisted with the visit. The facility is approved for serve the Developmentally Disabled clients AGE RANGE 18 THROUGH 59. FOUR (4) AMBULATORY ONLY. The facility is licensed as a 4G home vendored by San Gabriel Pomona Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing and staff disinfected the facility every shift . The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, dining area, kitchen, staff office, two clients bedrooms, two clients bathrooms, one isolation room and a detached garage. The laundry area is located in the backyard. Each client bedroom has two beds, two night stands, two chairs, required beddings and furniture and sufficient lighting and closet space. The two clients bathrooms are clean, sanitary and in a good working condition. The hot water temperature in both clients bathrooms were tested between 115.3 and 116.6 degrees F which are within the Title 22 regulation. All the appliances in the kitchen and living room are working properly. All the knives and sharp utensils are stored and locked in the room next to the entrance door. All the cleaning supplies and chemicals are stored and locked in the room next to the entrance door. The extra personal hygiene products are stored under the sink in the bathroom#1. The hallway night would always on at night time while the client need to access the non-private bathroom.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 II	FACILITY NUMBER: 198603415
	VISIT DATE: 12/19/2023

NARRATIVE

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The passageway, walkway and patio are free of obstruction. The carbon monoxide detectors and smoke detectors are interconnected and they are working well.

3. Operation Requirement: The facility is approved or licensed for four (4) ambulatory clients only and currently all clients are ambulatory. The last fire drill was conducted on 11/7/23. The facility has a shaded area patio with table and chairs for client to utilize the outdoor activity. The facility would allow client to attend community activities if there's a chance or opportunity.

4. Staffing: The facility has sufficient staffing to provide care and supervision to clients. LPA inspected the NOC shift staff and the staff has the required facility planned emergency procedure training in file.

5. Personnel Records/Training: All the staff files are stored in the locked cabinet in the staff office. All the staff are over 18 years old, fingerprint cleared and associated with the facility. LPA inspected three staff files and they all have the required documents which included: employee application, health screening, TB test result, required training hours and updated first aid and CPR certificate. The current administrators are Valentine Kamara and Linda Williams and their administrator certificate expiration date on 7/13/24 and 7/14/24 and they all have the updated HIV and TB Test training certificate.

6. Client's Right-Information: Currently there's no client is required any postural support. The facility does provide internet service with at least one internet access device for them to communicating with their day program or their families if needed.

7. Food Service: The facility has a ample supply of 2 days perishable and 7 days non perishable food in the facility. All the food are stored properly. Currently no client is on any modified diet that prescribed by physician. All client receive three meals a days and snacks in between the day.

8. Client Records-Incident Reports: All the clients files are stored in file cabinet in the staff office. LPA inspected all four (4) clients files and they have all required documents include: face sheet, functional capability assessment, admission agreement, physician report, individual program plan (IPP) and medication list and ambulatory status.

(See LIC809C for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VINTAGE HOME II	FACILITY NUMBER: 198603415
	VISIT DATE: 12/19/2023

NARRATIVE

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9. Health Related Services: The facility would provide transportation for client's medical and dental appointments. LPA inspected all four (4) clients medication. All medication are centrally stored and locked in the storage cabinet next to the kitchen. All clients medication are accurate and up-to-dated and they all have 30 days supply of medication.

10. Incidental Medical Services: Currently there's no client is under any restricted health condition plan and no client has any prohibited health condition in the facility.

11. Disaster Preparedness: The facility emergency disaster plan was updated on 12/2023 and the last emergency drill was conducted on 11/7/23. The facility also has two appropriate alternative shelter location.

12. Emergency Intervention: The facility does not use any restraint on client but all staff have the updated CPI Training.

No deficiencies were observed at the annual inspection.

Exit Interview Conducted and a copy of the report was provided to Administrator Linda Williams.

(LPA was not able to interview any client in the facility as all clients went to day program and no client was home while LPA was there.)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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