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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880706
Report Date: 07/27/2021
Date Signed: 09/21/2021 03:29:13 PM

Document Has Been Signed on 09/21/2021 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ELITE RESIDENTIAL CARE - THE VINEYARDFACILITY NUMBER:
331880706
ADMINISTRATOR:MCVEY, KARENFACILITY TYPE:
735
ADDRESS:41697 ZINFANDEL AVETELEPHONE:
(951) 240-7141
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY: 6CENSUS: 3DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Courtney UchiyamaTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced annual inspection. LPA met with Courtney Uchiyama. The home is licensed for 6 ambulatory residents.

The home is a four (4) bedroom, two (2) bath home with a living room, dining room and kitchen. All bedrooms are furnished with bed, night stand, dresser and chair. Bedrooms have adequate lighting for residents’ use. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The kitchen was observed to have dishes, silverware, pots, and pans. Staff and resident files are locked in the hall closet. The medications are locked in the dining area. The chemicals are locked and kept in a separate garage area. The backyard was observed to be fully fenced with an unlocked gate and has shaded area with table and chairs for client’s comfort while sitting outside.

During the visit LPA discussed infection control procedures and practices with Courtney Uchiyama . The home appeared to be in compliance and no deficiencies were observed or cited.

An exit interview was conducted and a copy of this report was reviewed with and provided to Ms Uchiyama
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2021
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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