331881452-9-7-2023-18-AS-SMAZ-CVFQH9-20230907121046

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881452
Report Date: 09/07/2023
Date Signed: 09/07/2023 12:10:55 PM

Document Has Been Signed on 09/07/2023 12:10 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SENIOR ASSISTED LIVING AT VINTAGE RESERVE LLC		FACILITY NUMBER:	331881452
ADMINISTRATOR:	BARROSO, MARIBEL		FACILITY TYPE:	740
ADDRESS:	40147 GRENACHE COURT		TELEPHONE:	(951) 719-0270
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY:	6	CENSUS: 0	DATE:	09/07/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:17 AM
MET WITH:	Maribel Barroso - Licensee		TIME COMPLETED:	12:19 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Sara Martinez conducted an announced visit to complete the Pre-licensing inspection. LPA met with Licensee, Maribel Barroso for a Residential Care Facility for the Elderly with a capacity of six (6) residents. The facility is a six (6) bedroom, three (3) bath home. There are five (5) resident bedrooms, one (1) staff room, kitchen/dining area, one (1) living room area, a laundry room, attached garage and backyard. LPA toured the interior and exterior areas of the facility. The following were inspected: Resident Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, lighting, and emergency lighting. Resident Bathrooms: The bathroom appliances were operating in safe and sanitary condition. The bathrooms have non-slip mats. Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. The knives and sharp objects were locked in the drawers. The water temperature was measured by LPA, the thermometer read at 115 degrees F. Common Sitting Areas: There is adequate seating in the common areas. The common seating area has a storage locker that will hold resident files and staff files. The facility will have a locked medication cabinet in the sitting area and will have an eMARs system set up.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SENIOR ASSISTED LIVING AT VINTAGE RESERVE LLC	FACILITY NUMBER: 331881452
	VISIT DATE: 09/07/2023

NARRATIVE

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Laundry Room, Linens and Hygiene Supplies: The laundry room is near the attached garage. The facility will keep the detergents and cleaning chemicals in locked cabinets located in the laundry room. An adequate supply of clean linens and hygienic supplies for the residents were readily available at the facility.

Backyard: The facility does not have any bodies of water on the property. There is a covered area with seating for the all the resident. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There are two (2) charged fire extinguishers in the facility. LPA observed operating smoke detectors, carbon monoxide alarms, and a sprinkler system located in every room in the facility. The home does not have any firearms and ammunition.

Postings: LPA observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, and personal rights.

First aid and working telephone: The facility was equipped with a complete first aid kit and manual. The facility has working telephone for resident use.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA has determined that the facility met the operational requirements for licensure. The Pre-licensing inspection is complete, and the facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Licensee Maribel Barroso.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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