507000307-10-13-2023-27-AS-KHOS-CZZKJL-20240131065650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507000307
Report Date: 10/12/2023
Date Signed: 10/13/2023 08:00:15 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/07/2023 and conducted by Evaluator Kimberly Viarella

COMPLAINT CONTROL NUMBER: 27-AS-20230807114928

FACILITY NAME:	VINTAGE FAIRE RESIDENTIAL		FACILITY NUMBER:	507000307
ADMINISTRATOR:	PRITHIKA B SINGH		FACILITY TYPE:	740
ADDRESS:	3620-A DALE ROAD		TELEPHONE:	(209) 521-1798
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	49	CENSUS: 41	DATE:	10/12/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Prithika Singh - Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff are not addressing bed bug infestation at the facility.

INVESTIGATION FINDINGS:

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On 10/12/23, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to continue the investigation into the above allegation. LPA identified herself, the purpose of the visit, and asked to speak with the Designated Facility Administrator. LPA met with Prithika Singh and a brief interview followed.

LPA toured the facility and observed several residents in the common room watching TV. Many of the doors to resident rooms were open and this LPA visited with 3 and spoke to one visitor. 3 out of 3 stated that they were happy with the care they were receiving. LPA interviewed one resident, (R1) regarding the above allegations. R1 stated they thought they had seen 3 live bed bugs in their room. LPA asked R1 if they would like the LPA to have staff check R1's bed. R1 said yes. LPA came back with a maintenance supervisor and the two inspected the bed and the surrounding area. LPA observed 4 live bed bugs; 1 on the wall behind the headboard and 3 on he carpet near the baseboard. Pest control services were already scheduled to perform a service and that room was added to the list.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230807114928

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VINTAGE FAIRE RESIDENTIAL	FACILITY NUMBER: 507000307
	VISIT DATE: 10/12/2023

NARRATIVE

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LPA requested the following documents and began interviewing staff.

The following documents were requested:
LIC 500 with contact information
Staff schedule for !0/12/23: Day , Evening and NOC shifts
Resident Roster with Emergency Contact Information
Pest Control Contract and service receipts for that past 6 months
Housekeeping schedule
Shower Schedule
LIC 624s involving resident on resident altercations from June - August 2023

Upon reviewing the Pest Control contract and receipts for treatment services, this LPA learned that although treatments have taken place, the facility did not have a specialized contract designed to eliminate /prevent the return of bedbugs. The pest control service relied on residents or staff reporting that they had witnessed bed bug activity and then the pest control service would come and treat the room(s).

Based on a review of records and confirmed through interviews with the Designated Facility Administrator, there have been repeated outbreaks of bed bugs in the same rooms. The room that this LPA observed bed bugs in on 10/12/23 had previously had bed bugs a year ago, per the Designated Facility Administrator.

The preponderance of the evidence has been met. This allegation has been SUBSTANTIATED.

The deficiency observed has been cited on the LIC 9099-D page.

A copy of this report and Appeal Rights were provided.

Exit interview.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20230807114928

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VINTAGE FAIRE RESIDENTIAL	FACILITY NUMBER: 507000307
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/19/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include...policies and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	The Licensee shall create a policy specific to the elimination of bedbugs and the maintenance of a bed bug free facility. It shall be submitted to kimberly.viarella@dss.ca.gov. The facility shall also install bed bug monitors under every resident bed in order to track
	8 9 10 11 12 13 14	Based on observation, interview and records review, the licensee did not comply with the section cited above in that there have been repeated observations and treatments for active bed bugs in the facility, however, they have not implemented an effective plan to eliminate the problem.	8 9 10 11 12 13 14	activity. Bed bug inspections will increase to twice a month by their contracted pest control agency and an "All Staff" training on bed bugs will be completed by the Facility Administrator. SIgnature sheets as proof of attendance will be submitted to licensing by 10/31/23
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

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