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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701112
Report Date: 10/21/2024
Date Signed: 10/21/2024 02:33:58 PM

Document Has Been Signed on 10/21/2024 02:33 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/
DIRECTOR:		BALLESTEROS, FLORENCIOFACILITY TYPE:
735
ADDRESS:7544 REMOULADE WAYTELEPHONE:
(916) 829-2774
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 4CENSUS: 4DATE:
10/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Florencio BallesterosTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/21/24 at 1:30p to conduct a Case Management visit. LPA met with Florencio Ballesteros and stated the purpose of the visit.

LPA toured the facility to observe bedroom #1 to have an enclosed entry way to the bathroom which is different from the floor plan submitted to Community Care Licensing (CCL) and Regional Center.

LPA requested a copy of the building permit and floor plan. Florencio stated that the documents were provided to CCL, however, LPA Brown did not locate the documentation.

LPA also observed the Licensee removed the mudroom and made the walk-in-closet into a staff room with the connecting bathroom. Bedroom #1 occupant is to use the bathroom # 3.

LPA also observed that the Licensee did not request a waiver to allow resident in bedroom #1 to have a bed without a frame.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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Document Has Been Signed on 10/21/2024 02:33 PM - It Cannot Be Edited


Created By: Victoria Brown On 10/21/2024 at 02:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VINEYARD HOME CARE, INC.
FACILITY NUMBER: 342701112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2024
Section Cited
CCR
80086(a)(b)

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Alterations to Existing Building or New Facilities
Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
The licensing agency shall have the authority to require that the licensee have a building inspection by a local building inspector if the agency suspects that a hazard to the clients' health and safety exists.
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Licensee shall submit a copy of the building permit and fire clearance for the alterations made to the facility. Fax to CCL by POC due date.
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This requirement is not met as evidenced by: Based on Licensee did not obtain authorization through a building permit and/or fire clearance for alterations. This possess a potential health and safety risk to residents in care.
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Type B
10/25/2024
Section Cited
CCR85088(c)(1)

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Fixtures, Furniture, Equipment and Supplies
The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.
An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).
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Licensee shall submit a copy of the residents IPP and a request to waive the use of a bed frame. Fax to CCL by POC due date.
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This requirement is not met as evidenced by: Based on Licensee did not obtain a waiver to allow resident to sleep on a mattress and not a complete bed. This possess a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024


LIC809 (FAS) - (06/04)
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