366424426-4-2-2024-56-AS-AFAL-D3XRCR-20240402125443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366424426
Report Date: 04/02/2024
Date Signed: 04/02/2024 12:54:58 PM

Document Has Been Signed on 04/02/2024 12:54 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 II, THE		FACILITY NUMBER:	366424426
ADMINISTRATOR:	ARNOLD P. MANSAT		FACILITY TYPE:	740
ADDRESS:	21292 CHARDONNAY DRIVE		TELEPHONE:	(760) 961-2658
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92308
CAPACITY:	6	CENSUS: 3	DATE:	04/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Mayleen Saludez - Administrator		TIME COMPLETED:	01:00 PM

NARRATIVE

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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 administrator Mayleen Saludez. The facility is approved for a Hospice Waiver for six (6) non-ambulatory residents, on of whom may be bedridden. LPA and Administrator 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 109 and 117 degrees Fahrenheit. Grab bars, textured shower floors, and shower aid equipment are utilized by residents. Fire safety installations such as extinguishers, sprinklers, and alarms are present. Fire extinguishers were observed to be charged and last inspected on 06/27/2023. Bedroom smoke detectors and carbon monoxide detector were tested by Administrator and units were observed working. Overall the facility is in good condition; it is clean, sanitary and free of foul odors.

Kitchen and Food Service: LPA was present during lunch service. The facility follows residents' special dietary needs. There is at least a one week supply of nonperishable foods and two days of perishable food items, which meets regulatory requirements. All readily perishable food or beverages capable of micro-organism growth are being stored in covered containers at appropriate temperatures. Sharps and cleaning agents are kept locked and secured.

Medication, Care, and Supervision: The facility has sufficient and competent staff to provide services needed to meet resident 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.

Resident and Staff Files: LPA reviewed all staff and resident files. Resident files had the required documents

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Fannell	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

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 II, THE	FACILITY NUMBER: 366424426
	VISIT DATE: 04/02/2024

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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, 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 observed two bedridden residents are occupying the bedridden room. This poses an immediate health and safety risks to residents in care. Refer to LIC809D for deficiency cited. Technical advisories were issued to remind staff of current and updated regulations. An exit interview was conducted where this report, LIC 809D, and appeal rights were discussed and provided to Administrator Saludez.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Fannell	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/02/2024 12:54 PM - It Cannot Be Edited

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 II, THE	FACILITY NUMBER: 366424426
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Administrator observations and resident records reviewed, the licensee did not comply with the section cited above as two bedridden residents are occupying the approved bedridden room, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2024
	Plan of Correction
1 2 3 4	Licensee shall submit a request to increase bedridden capacity to the Department no later than end of POC date. Licensee shall provide proof to LPA no later than end of POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Fannell	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC809 (FAS) - (06/04)

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