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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701112
Report Date: 03/22/2024
Date Signed: 03/22/2024 04:06:27 PM


Document Has Been Signed on 03/22/2024 04:06 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:VINEYARD HOME CARE, INC.FACILITY NUMBER:
342701112
ADMINISTRATOR:BALLESTEROS, FLORENCIOFACILITY TYPE:
735
ADDRESS:7544 REMOULADE WAYTELEPHONE:
(916) 519-7474
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:4CENSUS: 4DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Florencio BallasterosTIME COMPLETED:
04:30 PM
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On 3/22/24, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a Required - 1 Year visit. Upon arrival, facility staff Omaran Shah was present and contacted Administrator Florencio Ballesteros who arrived a bit later. LPA met with Administrator Florencio Ballesteros and explained the purpose of today’s visit. Administrator holds certification #6041668735 and expires on 7/15/2024. There are 4 clients in care.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed the facility is clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed 2-day perishables and 7-day non-perishables. The hot water temperature was measured at 111.2*F which was within the required range of 105-120*F. The temperature inside the facility measured at 72*F which was within the required range of 68-85*F.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. All emergency exits were clear from obstructions.

LPA requested client and staff files for review. LPA reviewed (4) client files and (3) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were observed during today's visit. Exit interview was conducted and a copy of the report was provided upon exit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
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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