<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004515
Report Date: 08/31/2021
Date Signed: 09/01/2021 10:28:37 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HOUSE AT VINEWOODFACILITY NUMBER:
306004515
ADMINISTRATOR:LINDA P. BOLIVARFACILITY TYPE:
740
ADDRESS:17382 VINEWOOD AVENUETELEPHONE:
(714) 486-1810
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:6CENSUS: 5DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Rodolfo De CastroTIME COMPLETED:
03:00 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) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year Annual inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez met with Staff Rodolfo De Castro and Lucena Prietos. Staff De Castro confirmed there are currently no cases or exposures of COVID-19 within the facility. LPA was screened upon entry into the facility and asked to use a hand sanitizer/hand wash. Administrator Linda Bolivar was unavailable.
LPA observed the required Department posting on COVID-19 precautions at entrance of facility. There is a sign-in procedure in place and hand sanitizer for use. LPA observed that all staff were wearing face masks. The facility has an approved Mitigation Plan on file with CCLD. There are 4 residents present during this visit. 5th resident is hospitalized. LPA conducted a tour of the facility and made observations pertaining to the facility's Infection Control measures. LPA toured all resident rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper and paper towels. Restrooms had proper hand washing signs posted. Facility has operating smoke and carbon monoxide detectors. Facility has Fire Extinguisher which was charged. LPA observed a copy of Administrators Certificate which expires 02/15/2023. The facility was equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. Personal Protective Equipment (PPE) supply is available. The facility monitors the residents regularly for any COVID-19 symptoms/change of condition and documents. Facility has required Emergency Disaster Plan, and a secured location for resident's medication and files. Facility has 30 days supply of medications for the residents. Residents emergency contact information and Physicians reports are current. LPA noted room #1 on floor plan is Caregiver room. Currently this room is being used as a resident room. LPA spoke with Staff 1 who stated he sleeps in the living room on a fold up cot. LPA observed storage room next to kitchen on the floor plan was converted into a staff room; Staff 2 confirmed she sleeps in this room on a fold up cot.
Based on observations made during today’s inspection, the following deficiency is being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with Staff De Castro. Report will be emailed to email on file.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HOUSE AT VINEWOOD
FACILITY NUMBER: 306004515
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interviews, and review of floor plan, the licensee did not comply with the section cited above in that what is to be staff room on floor plan is currently used by Resident 1. Staff 1 is sleeping on fold up cot in the living room. Staff 2 is sleeping in storage room next to kitchen, which was converted into staff room. This poses a potential health, safety or personal rights risk to persons in care and staff.
POC Due Date: 09/06/2021
Plan of Correction
1
2
3
4
Licensee/Administrator to submit a plan of correction by close of business day of 09/06/2021.
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: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3