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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507000307
Report Date: 03/16/2021
Date Signed: 03/16/2021 03:44:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:VINTAGE FAIRE RESIDENTIALFACILITY NUMBER:
507000307
ADMINISTRATOR:PRITHIKA B SINGHFACILITY TYPE:
740
ADDRESS:3620-A DALE ROADTELEPHONE:
(209) 521-1798
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:49CENSUS: DATE:
03/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Joyce PrasadTIME COMPLETED:
03:30 PM
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Licensing Program Analyst Charlie Yang contacted the facility via telephone to conduct a case management on 03/16/2021 due to concerns about the facility physical plant. LPA identified himself and discussed the purpose of the call and the elements of the case management with Business Services Manager Joyce Prasad.

The purpose of the case management visit was to follow up on a concern learned through an incident report. The following concerns were addressed:

Bed bugs were discovered in the facility and facility response

Extermination procedures and scheduling to completely eradicate the bed bug issue

Ongoing pest control on a monthly basis and continual review for bed bugs

An exit interview was conducted, and a copy of this report was given to Joyce Prasad via e-mail due to Covid-19 precautions. Business Services Manager Joyce Prasad will return report via email.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021
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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