198603415-1-29-2026-28-AS-BPEA-DQSVSN-20260129154148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603415
Report Date: 01/29/2026
Date Signed: 01/29/2026 03:42:06 PM

Document Has Been Signed on 01/29/2026 03:42 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
MONTEREY PARK ASC, 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:	01/29/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Linda Williams - Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:00 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) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Nwachukwu Nwokoro, DSP II and Nkechi Alozie, DSP II and explained the purpose of the visit. Administrator, Linda Williams was called on the phone and arrived at 1:20pm to assist LPA. The facility is licensed to care for Developmentally Disabled Adults, ages 18 through 59, (4) ambulatory only. All clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Staff are adhering to infection control requirements. Administrator reviews/updates the Infection Control plan annually. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood, contains a total of (3) bedrooms, of which (2) are client bedrooms and (1) spare/covid room, (2) full bathrooms, a living room, dining area, office, kitchen, backyard, and attached garage. Currently, there are (4) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom contained the required bed with bedding, mattress cover/sheets, blankets, bedspread, furniture, lighting and sufficient storage space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and area provides a shade with outdoor furniture. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. LPA observed (1) fire extinguisher which was last serviced on 10/28/2025. Smoke alarms and carbon monoxide were tested and operable. Water temperature readings were tested in all bathrooms and measured within the required 105 - 120 degrees Fahrenheit. Fire/disaster drills are conducted monthly on each shift. Last drill was conducted on 01/08/2026. Operational Requirements: All clients in the facility are ambulatory. Surety Bond is valid, expiring on 01/11/2027 and insured in the amount of $6000. Backyard has a covered patio and equipped with chairs for clients to utilize during outdoor activity. ***REPORT CONTINUED ON LIC809-C***

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VINTAGE HOME II	FACILITY NUMBER: 198603415
	VISIT DATE: 01/29/2026

NARRATIVE

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Staffing: Sufficient staff observed to meet clients needs. There are staff providing night supervision to assist and supervise the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expires on 07/14/2026. Administrator has completed HIV/TB Training and is valid.
Clients Rights-Information: Facility provides internet services to all clients and have access to the facility phone. No client in the facility required any postural support.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There are no clients with special diets residing at this facility.
Client Records-Incident Reports: LPA reviewed all client files maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Incident reports, Client Personal Property and Clients Personal Rights observed.
Health Related Services: Medications are centrally stored and reviewed for all clients. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician and are bubbled packed.
Incidental Medical Services: There are no clients at this home with a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. LPA asked the Administrator to update the plan to ensure information is current.
Emergency Intervention: Not-Applicable.

The Administrator was reminded of the licensing fees due on 01/19/2026.

No deficiency cited. Exit interview and a copy of this report was provided to the Administrator, Linda Williams.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC809 (FAS) - (06/04)

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