366412839-4-9-2024-56-AS-AFAL-D46QV4-20240409122942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366412839
Report Date: 04/09/2024
Date Signed: 04/09/2024 12:29:57 PM

Document Has Been Signed on 04/09/2024 12:29 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	VINEYARD RESIDENTIAL, THE		FACILITY NUMBER:	366412839
ADMINISTRATOR:	MAYLEEN VELASCO SALUDEZ		FACILITY TYPE:	740
ADDRESS:	21246 SAUVIGNON LANE		TELEPHONE:	(760) 240-9312
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92308
CAPACITY:	6	CENSUS: 3	DATE:	04/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Janette Mabutas - Care Provider		TIME COMPLETED:	12:33 PM

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Licensing Program Analyst (LPA) Anna Fannell conducted an unannounced visit to this facility for a required annual inspection. Entry into the facility is unobstructed and LPA met with care staff Janette Mabutas who was informed of the purpose of today's visit. Mabutas notified administrator Mayleen Saludez and Administrator arrived at the facility. The facility is approved for a Hospice Waiver for six (6) non-ambulatory residents, all of whom may be bedridden. Administrator left the facility before the conclusion of the visit. LPA and Staff toured the interior and exterior of the facility.

Physical Plant: There are no pools or other bodies of water located on the premises. The facility is being maintained at a comfortable temperature for residents. All passageways are kept free of obstruction. Hot water temperature was measured in all bathrooms and measured between 105 and 110 degrees Fahrenheit. Grab bars, textured/tiled shower floors, and shower aid equipment are utilized by residents. Fire safety installations such as extinguishers, sprinklers, and alarms are present. Fire extinguisher is kept in the laundry area and was observed to be charged and last inspected on 06/28/2023. Carbon monoxide detector and bedroom and hallway smoke detectors were tested by Staff and units were observed working. Overall the facility is in good condition, is clean and sanitary, and is not malodorous.

Kitchen and Food Service: LPA was present during lunch service. LPA observed food provisions and found a two-day perishable and at least a 7-day non-perishable supply. All readily perishable food or beverages capable of micro-organism growth are being stored appropriately within regulatory temperatures. Sharps and cleaning agents are kept locked and secured.

Medication, Care, and Supervision: The facility maintains sufficient staffing to provide services needed to meet residents' needs. Chemicals and cleaning agents are stored inaccessible to residents. LPA inspected medications and found them in original containers and appear to be dispensed according to doctors' orders.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Fannell	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VINEYARD RESIDENTIAL, THE	FACILITY NUMBER: 366412839
	VISIT DATE: 04/09/2024

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Resident and Staff Files: LPA reviewed all staff and resident files. Resident files had the required documents including admission's agreement, consent forms, and appraisal and/or needs and services plan. Staff files had the required documentation and training including mandated reporting, health screening report, and CPR certification.

Operations and Administration: Disaster Plan is present. Administrator is present in the facility a sufficient amount of hours and their administrator certification is up to date. The required ombudsman and licensing posters are posted in public view. Residents rights are posted and a copy is kept the resident's file.

During today's visit, LPA Fannell issued technical advisories to remind staff of current regulations. An exit interview was conducted where this report in its entirety was discussed and provided to care staff Janette Mabutas.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Fannell	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC809 (FAS) - (06/04)

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