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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701222
Report Date: 11/17/2023
Date Signed: 11/17/2023 02:14:49 PM


Document Has Been Signed on 11/17/2023 02:14 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:VINTAGE FARMHOUSE, THEFACILITY NUMBER:
342701222
ADMINISTRATOR:TILLER, KIMBERLYFACILITY TYPE:
740
ADDRESS:9316 APPALACHIAN DRIVETELEPHONE:
(916) 591-0426
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:6CENSUS: 5DATE:
11/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kimberly TillerTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 11/17/23 at 12:30pm. Administrator Certificate expires 4/24/24. Licensing fees are current.

LPA met with Diana Albu, Caregiver who contacted the Administrator Kimberly Tiller regarding the purpose of todays visit. Administrator arrived within 15 minutes to assist with todays visit. The facility is licensed for a capacity of 6 non-ambulatory residents in rooms 1-5 and the master bedroom of which 4 may receive hospice care services. There are 0 residents receiving hospice care services during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed and interviewed a random amount of residents. LPA observed 2-day perishables and 7-day non-perishables. The facility has an Infection Control Plan on file.

The temperature inside the facility was observed to be at 77 *F which is within the required range of 68-85*F. The hot water temperature was measured at 118.3*F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA reviewed 1 staff and 2 resident files and conducted interviews during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308), Control of Property, Administrator Certificate-Updated

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview held, copy of report given
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
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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