331800073-9-13-2024-18-AS-APEZ-D93VEZ-20240913162310

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800073
Report Date: 09/13/2024
Date Signed: 09/13/2024 04:23:24 PM

Document Has Been Signed on 09/13/2024 04:23 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	VINEYARD PLACE		FACILITY NUMBER:	331800073
ADMINISTRATOR/ DIRECTOR:	ARLENE CRAWFORD		FACILITY TYPE:	740
ADDRESS:	24325 WASHINGTON AVE		TELEPHONE:	(951) 387-8410
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY: 82		CENSUS: 53	DATE:	09/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:40 PM
MET WITH:	Administrator Thomas Taylor		TIME VISIT/ INSPECTION COMPLETED:	04:35 PM

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Licensing Program Analyst (LPA’s) Armando Perez and Kathleen Banrasavong made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA's were greeted by reception and contacted the Administrator Thomas Taylor Jr to meet with LPA's. The LPA's informed the Administrator of the purpose for the visit. The inspection included the following:

The facility has a census of 53 residents and is a single-story unit consisting of 64 bedrooms with private bathrooms. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. LPA's observed a kitchen with large refrigeration unit and a dinning area with sufficient setting and space for activities. A monthly activities calendar is kept in the dinning area. A laundry room is on site with locked cabinets. There are no bodies of water located on the property. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. LPA's observed two outdoor covered patios with seating.

LPA's began review of client records. 10 records were reviewed. LPA's reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

LPA's began review of employee records with 7 records were reviewed. LPA's reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 04/20/2025.

LPA's observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VINEYARD PLACE	FACILITY NUMBER: 331800073
	VISIT DATE: 09/13/2024

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Medications is stored in two separate secured locations. There is a locked cart inside the room allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

LPA's made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were previously tested found to be operational on 10/10/23. The facility is conducting emergency disaster/fire drills monthly.

Based on the information received during this visit today in the areas reviewed, there are no deficiency that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with the facility representative and a copy was provided.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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