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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004515
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:29:45 PM


Document Has Been Signed on 07/21/2022 03:29 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
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: 6DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Louie Armada and Linda BolivarTIME COMPLETED:
10:38 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Linda Bolivar arrived during the visit. LPA confirmed Administrator has a current administrator certificate expiring on 02/15/2023.
At 8:52 AM, LPA toured the facility with Administrator Linda Bolivar. Facility has 6 residents in care during today's visit with 2 residents on hospice care. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility however LPA was not screened upon entry. Facility utilizes a hand written visitor sign in sheet. Facility takes resident and staff temperatures daily and documents. LPA observed the first aid kit has all required items. Facility has completed the infection control plan and plan to be submitted to licensing. LPA observed an ample supply of emergency food. Smoke detectors tested operational during today's visit and fire extinguishers are mounted and charged. LPA toured the kitchen at 9:10 AM and observed the burners on the cook top are inoperable. LPA observed the shaded outside visitation area including a gated pool. Exit gates are self latching and unlocked. LPA observed the locked medication area. Facility provides activities in the form of exercise and games. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed all resident files during the visit and all files have updated emergency information as well as required documents. All residents and staff are vaccinated for Covid-19.
LPA consulted with Administrator regarding the importance of ensuring full bed rails are only utilized for hospice residents per physician order as well as the importance of hand washing signs in all facility restrooms..
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. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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 07/21/2022 03:29 PM - It Cannot Be Edited

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: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed all four burners on the cook top are inoperable and facility is using a lighter to start the burners. This poses a potential health and safety risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
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Licensee to repair/ replace the burners and forward proof to LPA by 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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