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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603126
Report Date: 07/14/2022
Date Signed: 07/14/2022 01:46:21 PM


Document Has Been Signed on 07/14/2022 01:46 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:VINTAGE RESIDENTIAL 1FACILITY NUMBER:
374603126
ADMINISTRATOR:GRAPE, CYNTHIAFACILITY TYPE:
740
ADDRESS:316 CRESTVIEW DRIVETELEPHONE:
(619) 271-3834
CITY:BONITASTATE: CAZIP CODE:
91902
CAPACITY:6CENSUS: 6DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Stephany Haro, CaregiverTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Daniela Huerta visited the facility to conduct an annual required licensing inspection. LPA disclosed the purpose of the visit, was granted entry into the facility, and met with Stephany Haro, Caregiver.

During today’s visit, LPA toured the facility and verified compliance with infection control practices. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents, and visitors; a sign-in policy enacted for visitors; signs in the facility to promote hand hygiene, cough/sneeze etiquette, symptom and transmission awareness; face coverings worn by staff; hand sanitizer/hand washing stations readily available; and an ample supply of cleaning products.

No deficiencies were cited during today’s visit. An exit interview was conducted with Stephany Haro, and a copy of this report and Licensee Rights (LIC 9058 FAS 01/16) was provided.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniela HuertaTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
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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