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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507000307
Report Date: 06/26/2023
Date Signed: 06/26/2023 10:33:23 AM


Document Has Been Signed on 06/26/2023 10:33 AM - 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, 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: 39DATE:
06/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Prithika Singh - AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 Year Annual Inspection Visit. LPA met with administrator and explained purpose of visit. Administrator's Certification expires . There are currently 39 residents at facility and there are 2 residents on hospice at this time.

LPA and administrator inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2 day perishable and 7 day nonperishable.
Fire extinguishers were last inspected on 9/26/2023. Smoke alarms were tested and are operational. The facility has a carbon monoxide detector and performs disaster drills as required. The hot water temperature was measured at 112.6*F which is within the required range of 105-120*F. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA reviewed 5 staff record files and the facility has sufficient staffing to provide the services needed to meet the residents’ needs. All staff have criminal record clearance and are associated to the facility. The facility serves residents with dementia and staff have received the necessary training hours specific to dementia. LPA reviewed 5 resident files which had all required documents.

There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA received the following updated documents for Community Care Licensing: LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Administrator’s Certificate and Liability Insurance

Exit interview conducted with administrator and copy of report left at facility
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023
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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