336426083-5-15-2025-18-AS-JGEE-DGPTGS-20250515144336

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426083
Report Date: 05/15/2025
Date Signed: 05/15/2025 02:43:45 PM

Document Has Been Signed on 05/15/2025 02:43 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:	ATRIA PARK OF VINTAGE HILLS		FACILITY NUMBER:	336426083
ADMINISTRATOR/ DIRECTOR:	MARIANO Q. HERNANDEZ		FACILITY TYPE:	740
ADDRESS:	41780 BUTTERFIELD STAGE RD		TELEPHONE:	(951) 506-5555
CITY:	TEMECULA	STATE: CA	ZIP CODE:	92592
CAPACITY: 143	TOTAL ENROLLED CHILDREN: 0	CENSUS: 119	DATE:	05/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:21 AM
MET WITH:	Mariano Hernandez, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	02:55 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	On 05/15/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required inspection. LPA met with Executive Director Mariano Hernandez, where LPA explained the purpose of the visit. The facility is licensed with an approved fire clearance to serve 81 non ambulatory and 62 bedridden. There is a delayed egress in Building A (Life Guidance/memory care). The facility has an approved hospice waiver for (21) with (19) residents currently receiving hospice services. The facility currently has zero (0) bedridden residents. During today's visit LPA verified facility contact information and will update accordingly. Below is a summary of observations made during today's inspection of Assisted living census: (73) and Memory Care, census (28). In Assisted living the building consists of an Ice cream parlor, Nurse's station, library, kitchen, multi purpose room, beauty salon, art and crafts room and laundry room. LPA observed for there to be a missing screen on the window inside the laundry room located on the second floor. There was no citation issued as it was put back on during LPAs visit. In memory care (building A), consists of three wings (Wisteria court, Magnolia court and Rose court). LPA observed for there to be a dining area, salon, laundry room, and a kitchen- serves beverages and warms the food that is prepared in the main kitchen. LPA conducted a tour of the interior and exterior areas of the facility. The facility was observed to be clean, clutter and odor free. The food supply was observed to be sufficient as there was a two day supply of perishable and a seven day supply of nonperishable food items. The facility does have a pool located on the independent living side/building. It is open to all residents for use however, it is rarely used. The facility

Anthony Perez	TELEPHONE: (323) 485-4915
Javina George	TELEPHONE: (951) 217-3970
	DATE: 05/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

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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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: ATRIA PARK OF VINTAGE HILLS	FACILITY NUMBER: 336426083
	VISIT DATE: 05/15/2025

NARRATIVE

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elevators were recently inspected February 2025. The facility has operable smoke and carbon monoxide detectors. LPA observed for there to be (4) fire extinguishers on each floor, that were last inspected on 12/22/24. Emergency disaster drills are being conducted on a quarterly basis, last drill was conducted on 2/26/25.

In assisted living the medications were observed to be locked inside a medication cart that is stored inside the medication room located on the second floor. The facility utilizes an electronic Medication Authorization Record System. The same applies for memory care, as LPA observed to be locked inside a cart inside the medication room. The pull cords were tested in random resident rooms and were found to be operable. The hot water was tested in assisted living measuring at 111-113 degrees Fahrenheit. In memory care the water was tested and ranged from 116-120 degrees Fahrenheit.

A file review was conducted and resident files were reviewed and were observed to have current resident assessments, and admission agreements. LPA reviewed random staff files and observed for the staff to have obtained criminal record clearance and to be associated to the facility. The staff files reviewed were observed to possess valid CPR certification, and training that is completed online and in person. In addition the Executive Director Mariano was observed to possess a valid administrator's certification that expires on 12/09/25.

During today's visit LPA gave a reminder of the amount for the facility annual fees, that are due on or before 06/30/25, and provided PIN 809985, should the licensee wish to pay electronically.

Based on today's inspection no citations were issued. An exit interview was conducted and a copy of this report and the LIC811-confidential names list was reviewed and provided to Mariano "Quinn" Hernandez, Executive Director.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

LIC809 (FAS) - (06/04)

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