198603415-1-16-2025-28-AS-ALOZ-DCYTDP-20250116133841

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603415
Report Date: 01/16/2025
Date Signed: 01/16/2025 01:39:06 PM

Document Has Been Signed on 01/16/2025 01:39 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/ DIRECTOR:	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:	01/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:52 AM
MET WITH:	Nwokoro Nwachukwu, DSP and Linda Williams, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:49 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Nwokoro Nwachchukwu, DSP and Administrator Linda Williams arrived a short time later and LPA explained the reason of the visit. The facility is approved for serve Developmentally Disabled Adults, four (4) ambulatory clients. The facility is licensed as a 4G home vendored by San Gabriel Pomona Regional Center.

The following was observed:

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility is disinfecting throughout the day.

2. Physical Plant & Environment Safety: The facility is free of debris. There are no security bars or weapons on the premises. The hot water temperature was tested, and temperature measured between 105.3 -117.8 degrees F which is within required range/ All storage areas for cleaning solutions, toxins, knives, and hazardous items are inaccessible to clients. The last Fire/Emergency Drill was 12/03/24. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed operational. The eaves of the home in the back on the north west corner need painting.

3. Operational Requirement: The facility is licensed for four (4) ambulatory clients and currently all four (4) clients are ambulatory. Clients can attend the community events/activities if there's an opportunity and chance. The facility has a shaded area with table and chairs for client to utilize the outdoor activity.

4) Staffing: A total of two (2) staff members provide care and supervision to the client during the day. At night there is one staff.

(Continued on 809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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: 01/16/2025

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(Continued from 809)

5. Personnel Records-Training. The facility staff files are at facility. All the staff are over 18 years old and older, fingerprint cleared and associated with the facility. The administrator is Linda Williams, Administrator and her administrator certificate expiration date is 07/13/2026, Administrator has updated HIV and TB training. LPA reviewed three (3) staff files and they all have the required documents including health screening, TB test result, updated first aid certificate and required training hours.

6. Client right-Information: Currently there's no client required postural support. The facility also has internet service and provide at least one internet access device in the facility.

7. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

8. Client Records/Incident Reports: All four (4) client files were reviewed containing admission agreements, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent.

9. Health Related Services: Clients are assisted with self-administration of prescription and non-prescription medications. Four (4) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked area and not accessible to clients in care. Medications are given according to Physician orders.

10. Incident Medical and Dental: Clients are assisted with medical and dental services.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan posted at facility but needs updating. .

12. Emergency Intervention: No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiency observed during the visit. Technical Advisory provided. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/16/2025 01:39 PM - It Cannot Be Edited

Created By: Alberto Lopez On 01/16/2025 at 01:33 PM

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: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, The eaves of the home in the back on the north west corner need painting. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	Administrator will paint the eaves of the home in the back on the north west corner and will send LPA proof by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Lisa Hicks

LICENSING EVALUATOR NAME:

Alberto Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC809 (FAS) - (06/04)

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