374603126-5-22-2024-08-AS-MGCO-D5HVLR-20240522163223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603126
Report Date: 05/22/2024
Date Signed: 05/22/2024 04:35:11 PM

Document Has Been Signed on 05/22/2024 04:35 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	VINTAGE RESIDENTIAL 1		FACILITY NUMBER:	374603126
ADMINISTRATOR:	GRAPE, CYNTHIA		FACILITY TYPE:	740
ADDRESS:	316 CRESTVIEW DRIVE		TELEPHONE:	(619) 271-3834
CITY:	BONITA	STATE: CA	ZIP CODE:	91902
CAPACITY:	6	CENSUS: 6	DATE:	05/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator, Cynthia Grape		TIME COMPLETED:	03:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Annual visit. LPA met with Administrator, Cynthia Grape, and we discussed the purpose of the visit. Grape is the certified administrator for the facility, and her Administrator's Certificate expires on 11/3/2024. The facility file was reviewed before the visit. According to the facility’s license, the facility is approved for six (6) non-ambulatory residents. Currently, the hospice waiver is approved for two (2) residents. During today’s visit, there were a total of six (6) residents in care, all of whom were non-ambulatory. There were three (3) staff at the facility, all staff had current criminal record clearance and current CPR certificates were on file. The facility was assessed by touring it inside and out. LPA inspected for compliance with safety, maintenance, and operational requirements. LPA interviewed staff, as well as general conversation with residents in care. All residents were observed to be clean, groomed, and free from bad odors. During the visit, five (5) residents were observed to be eating by themselves in the dining area. One resident required assistance with feeding. Administrator Grape indicated that there are no firearms stored on the premises. There were two (2) areas available for dining. Residents eat meals together three (3) meals per day most of the time. There were at least 2 days of perishable food, and at least 7 days of non-perishable food present, all safely stored. (continue at LIC809)

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VINTAGE RESIDENTIAL 1	FACILITY NUMBER: 374603126
	VISIT DATE: 05/22/2024

NARRATIVE

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(continue from LIC809)

There is a facility pool, and LPA toured the area. Access to the pool is restricted with fencing, locked accessible only by staff. The door was secured during LPA's visit. Exit doors equipped with alarms. The hot water temperature was measured during the visit (114 degrees F). The appliances in the resident rooms were in working order. Each room observed was clean, sanitary, and in good operating condition. Bathrooms inspected had grab bars installed, by the toilets and shower areas.

Cleaning supplies for the housekeeping staff were secured away from residents. Medications were labeled, as required and stored in locked areas. Keys to the medication cabinets were kept and controlled by appropriate staff with responsibility for medication management.

LPA interviewed staff and reviewed multiple staff and resident records/files. LPA interviews did not raise any licensing concerns. The files that LPA reviewed contained the required documents. Confidential records were stored in locked areas.

Facility staff conducted an emergency drill in February 2024. LPA discussed with staff the requirement to keep records for all emergency drills conducted, including the date, time, and staff/residents who participated as required. The facility updated its disaster and emergency preparedness plan in 2024 and facility liability insurance was current with an expiration date of January 2025.

No violations were observed during the visit.

During the visit, an exit interview was conducted with the Administrator, Grape, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC809 (FAS) - (06/04)

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