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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005248
Report Date: 12/16/2024
Date Signed: 12/16/2024 12:16:05 PM

Document Has Been Signed on 12/16/2024 12:16 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VINEYARD HOME CARE LLC.FACILITY NUMBER:
317005248
ADMINISTRATOR/
DIRECTOR:
SVISTUN, MIHAELAFACILITY TYPE:
740
ADDRESS:1329 CHAMPAGNE CIRCLETELEPHONE:
(916) 784-9204
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Miheala SvistunTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced to conduct an annual inspection.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed five (5) resident rooms and one (1) common area bathroom. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathroom was in sanitary condition, properly maintained, and the hot water temperature was observed to be 113.1 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care home. Fire extinguisher and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed six (6) resident files and two (2) staff files. Facility has a current copy of certificate of liability insurance and LPA obtained a copy.

As a result of this visit, no deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted with Administrator.
Anthony PerezTELEPHONE: (323) 485-4915
Cassandra MikkelsonTELEPHONE: 916-709-6830
DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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