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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881258
Report Date: 03/28/2025
Date Signed: 03/28/2025 03:16:39 PM

Document Has Been Signed on 03/28/2025 03:16 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VINEYARD RANCH AT TEMECULAFACILITY NUMBER:
331881258
ADMINISTRATOR/
DIRECTOR:		KELLEY LARAFACILITY TYPE:
740
ADDRESS:27350 NICOLAS ROADTELEPHONE:
(951) 308-1988
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY: 98CENSUS: 89DATE:
03/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator, Kelley Lara TIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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On 3/28/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Administrator, Kelley Lara who was informed of the purpose of the visit. The facility is licensed to serve for 98 elderly non-ambulatory elderly residents, of which 10 may be bedridden. The facility also has an approved hospice waiver for 26 residents and LPA was informed eight (8) residents are currently receiving hospice services at the facility.

LPA toured the facility and observed the facility is made up of a two-story building currently designated for assisted living and memory care. The facility has large dining rooms, a cinema, fitness room, library, piano bar, game room, along with other activity rooms available for resident leisure. LPA toured the kitchen and observed food was stored in a safe and healthful manner. The facility met Departmental requirements for a two-day supply of perishable foods and seven-day supply of non-perishable food items. LPA observed a white board on the kitchen wall noting residents' dietary needs. LPA observed fire alarm systems, carbon monoxide detectors, and charged fire extinguishers throughout the facility. LPA reviewed the Annual Fire Alarm Report dated 4/10/2024 provided by HCI Systems Inc. noting the fire alarms and signaling systems passed their inspection. LPA was informed the facility's last fire drill was conducted on 3/22/2025. Medications are secured in medication carts stored in the locked medication room. Cleaning solutions and disinfectants are secured in the locked housekeeping room. The courtyard provides outside shaded seating for residents in care. Indoor and outdoor passageways were free of obstruction. No bodies of water were observed on the premises. The facility is pending a capacity change as it is expanding and undergoing new construction, which the Department is aware of. Administrator Lara will provide clarification regarding the fire inspection request by close of business on 4/1/2025.

During today's visit, LPA did not observed any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Kelley.

NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Janette Romero
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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