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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881258
Report Date: 04/07/2023
Date Signed: 04/07/2023 03:46:21 PM


Document Has Been Signed on 04/07/2023 03:46 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:VINEYARD RANCH AT TEMECULAFACILITY NUMBER:
331881258
ADMINISTRATOR:KNAUER, KURTFACILITY TYPE:
740
ADDRESS:27350 NICOLAS ROADTELEPHONE:
(951) 308-1988
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY:98CENSUS: 93DATE:
04/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Kurt KnauerTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 4/7/2023 at 09:45 a.m. LPA met with Administrator Kurt Knauer, who was informed of the purpose of the visit.

The facility is a two story building with a total capacity of (98) residents, (88) of which may be non-ambulatory, and (10) of which may be bedridden, The residents served are elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted (5)staff and (5)resident interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen. LPA observed gloves and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures. LPA observed PPE supplies at the facility. The LPA reviewed infection control training conducted with facility staff which met the department requirements.



Physical Plant/Planned activities: LPA observed the resident bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. There is no pool or bodies of water. Laundry room was observed to be locked and equipment was observed to be in working condition. Hot water temperature was recorded at 111.2F in a resident restroom.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VINEYARD RANCH AT TEMECULA
FACILITY NUMBER: 331881258
VISIT DATE: 04/07/2023
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Care & Supervision/Administration: LPA observed adequate staff are present for the supervision of residents. Emergency exiting plans, personal rights, ombudsmen, and complaint information were found posted in the facility. The listed administrator, possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed (5) staff files. All staff have updated training along with CPR/First Aid Certification. LPA reviewed the staff schedules and rosters for the facility. LPA compared this to the Guardian roster and found that several staff members where missing on the guardian roster. LPA reviewed (5) staff files of which (1) was on the guardian roster and (4) were not. LPA reviewed the staffs file and found that the staff had clearance numbers and transfer sheets along with dates and copies of envelopes sent to (CPMB). LPA called the regional office to verify clearance for the remaining (4) staff reviewed and found that (3) of the (4) staff were associated to the old facility number ending in 0114. (1) staff was associated to the facility ending in 258. LPA reviewed the transfer forms and found that the facility number being written was ending in 0114. All staff checked possessed a valid clearance. The staff hired prior to the new facility number are currently still on the old facility number. LPA will inquire with Guardian to have the staff transferred to the new facility number. Five (5) resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medications were locked in a medication room. LPA reviewed resident medications and found all required labeling was found to be in place. LPA observed the facility has a first aid kit on the premises with all required articles.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility last disaster drill on 2/2/2023, which met the department requirements. LPA observed all facility exits were clear from obstructions, and evacuation routes were posted at the facility. LPA observed the facility's emergency supplies and LIC610D along with disaster preparedness binder.

No deficiencies where issued at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Administrator, Kurt Knauer.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC809 (FAS) - (06/04)
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