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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412839
Report Date: 05/01/2025
Date Signed: 05/01/2025 01:16:19 PM

Document Has Been Signed on 05/01/2025 01:16 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VINEYARD RESIDENTIAL, THEFACILITY NUMBER:
366412839
ADMINISTRATOR/
DIRECTOR:		MAYLEEN VELASCO SALUDEZFACILITY TYPE:
740
ADDRESS:21246 SAUVIGNON LANETELEPHONE:
(760) 240-9312
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
05/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Mayleen VelascoTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to this facility for a required annual inspection. LPA met with Administrator Mayleen Saludez and was informed of the purpose of today's visit. The facility is approved for a capacity of six (6) non-ambulatory residents with a current census of one (1) resident in care. LPA conducted a tour of the interior and exterior of the facility.

Physical Plant: All indoor and outdoor passageways are kept free of obstruction. There are no pools or other bodies of water located on the premises. The facility's outdoor activity space is enclosed with a self-latching gate. The facility is being maintained at a comfortable temperature for resident. Resident bedroom equipment are in operating condition and bathrooms are equipped with grab rails and slip mats. Hot water temperature in resident bathrooms measured between 105 degrees Fahrenheit. The facility is equipped with fire extinguishers, fire alarms, first aid kit, hallway night lights, bottled water and telephone service. The facility has posted in a common area: Community Care Licensing complaint poster, Ombudsman poster, facility license, evacuation sketch and emergency telephone numbers.

Kitchen and Food Service: The facility is equipped with a two-day perishable and at least a 7-day non-perishable supply of food. 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 and Supervision: The facility maintains sufficient staffing to provide services needed to meet residents' needs. Resident's medication is central stored and kept locked and secured.

Karen ClemonsTELEPHONE: (951) 248-0349
Magda MalcoreTELEPHONE: 951-248-0316
DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2025
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VINEYARD RESIDENTIAL, THE
FACILITY NUMBER: 366412839
VISIT DATE: 05/01/2025
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Record Review: Resident file had admissions agreement, physician's medical assessment, preadmission appraisals, reappraisal and/or needs and services plan. Staff files had criminal records clearances and/or exemptions, employment history, health screening, first Aid/CPR certifications and job related training. The facility has a client registry and disaster plan for review. The Administrator's certification and facility insurance are current.

Overall the facility is in good repair. No deficiencies where cited during today's visit. An exit interview was conducted were this report was discussed and copy was provided to Administrator Saludez at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC809 (FAS) - (06/04)
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