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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507000307
Report Date: 12/01/2023
Date Signed: 01/30/2024 01:16:47 PM

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 RESIDENTIALFACILITY NUMBER:
507000307
ADMINISTRATOR:PRITHIKA B SINGHFACILITY TYPE:
740
ADDRESS:3620-A DALE ROADTELEPHONE:
(209) 521-1798
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:49CENSUS: 38DATE:
12/01/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Prithika SinghTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff are not ensuring that residents' hygiene needs are being met while in care.
Staff do not ensure that residents are provided with adequate bedding while in care.
Staff do not prevent resident(s) from abusing other resident(s) in care.
Staff are not ensuring that residents' diapering needs are being met while in care.
Staff are not ensuring that residents take their medication(s) as prescribed while in care.

INVESTIGATION FINDINGS:
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This document has been amended to change the wording on the LIC 9099D page.
On 12/01/23, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation regarding the above allegations. LPA introduced herself, the purpose of the visit, and asked to speak with the Designated Facility Administrator (DFA). LPA met with Prithika SIngh and a brief interview followed.
Regarding: Staff are not ensuring that residents' hygiene needs are being met while in care.
During an unannounced visit on 10/12/23 to investigate this complaint, this LPA observed a resident in care with unwashed greasy hair. LPA took a photo for reference and spoke to staff about this resident. This LPA learned from staff that this resident (R5) did not like taking showers and would decline. When LPA returned a week later, R5’s hair was unwashed and R5 was wearing the same outfit. This LPA also learned during the course of this investigation that other residents have remained in the same clothes for consecutive days. On 10/12/23LPAs heard S4 mention to R5 that S4 thought R5 was wearing the same shirt they were wearing when they last saw R5. R5 confirmed that they had been wearing that shirt since their last
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
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: 12/01/2023
NARRATIVE
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shower 2 days ago. During this LPA’s visit on 10/12/23, LPA observed R6 barefoot and confused wandering the lobby, speaking softly stating that they were cold. LPA brought the Administrator out to assist R5. LPA observed long uncut toenail that were curling under. LPA took a photo for reference and brought the resident’s hygiene needs to the attention of the Administrator. The Administrator replied, “That resident has dementia and is on hospice.” This LPA reminded the Administrator that they should then call hospice and make arrangements for this resident’s care. On 10/19/23, LPAs Viarella and Valerio observed another resident with long uncut toenails that had begun to curl downward. LPA Viarella took a photo for reference. Based on observation and interviews, the preponderance of the evidence standard has been met and the department found the allegation, “Staff are not ensuring that residents' hygiene needs are being met while in care,” to be SUBSTANTIATED.

Regarding: Staff do not ensure that residents are provided with adequate bedding while in care.
On 11/15/23 Licensing Program Analyst (LPA) Kimberly Viarella and Licensing Program Manager (LPM) Stephen Richardson made an unannounced visit to this facility to continue this complaint investigation. This LPA interviewed 7 staff members and 6 residents. All stated that there was enough bedding, and if a resident requested additional linens or blankets, the facility had an adequate house supply on hand to meet any requests. LPA/LPM inspected the House supply and found that the facility only had 5 blankets in reserve. If anything were to happen to the heating system, or if there were a particular cold front or emergency situation, there would not be enough bedding for the residents in care. The preponderance of evidence standard has been met and the department found this allegation to be SUBSTANTIATED.

Regarding: Staff do not prevent resident(s) from abusing other resident(s) in care. During this LPA’s 3 separate visits on 08/09/23, 10/12/23, and 10/19/23, this LPA did not observe any resident conflicts or aggression. However, during the course of this investigation, this LPA learned that on 10/04/23 the Modesto Police responded to an incident of battery involving 2 residents. The police report also stated that “this is an ongoing issue with the same suspect at Vintage Faire.” The preponderance of evidence standard has been met and the department found this allegation to be SUBSTANTIATED.

Regarding: Staff are not ensuring that residents' diapering needs are being met while in care.


LPA found this facility to be malodorous on 08/09/223, 10/12/23, and 10/19/23.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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: 12/01/2023
NARRATIVE
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LPAs learned that at the present time, NOC shift were responsible for the incontinent care of 19 residents. During a tour of the facility on 10/19/23, LPAs observed the carestaff assisting a minimum of 5 residents in their rooms with their incontinent care. LPAs observed a sign in the employee breakroom which stated, “Get 4-6 residents up by 6:45 AM fully dressed and ready for breakfast.” LPAs heard 2 residents complain with raised voices that they wanted to be left alone. Of the two, LPA Valerio observed that carestaff were able to achieve compliance with one, who cooperated with carestaff upon their second visit to their room. LPAs were unable to confirm if the remainder of the 19 residents with an incontinence care plan were assisted prior to their arrival. By 7:00 AM, NOC staff moved on to distributing medication and preparing residents for breakfast at 8:00 AM. 4 out of 5 staff interviewed confirmed that residents’ incontinent care needs were not being met as evidenced by saturated briefs, clothing, and beds. On 10/19/23, LPAs observed 3 residents that required a 2 person assist to reposition and be changed.

During the course of this investigation, this LPA reviewed punch logs for NOC employees from 10/25/23 to 11/25/23. This LPA learned that on 22 separate occasions, only 1 staff member was in the building to care for the 35+ residents in care from 11:00 PM - 6:00 AM. This presented a health and safety risk to residents in care who could have possibly been injured since assistance with transferring, repositioning, and changing, was not available. Their care plan could not be followed at that time as it wasn’t possible to adequately attend to the needs of those who required a 2-person assist. If a resident fell and there was only one carestaff present, they have been instructed to call 911 to request a lift assist from non-emergency personnel. On 10/12/23 the Designated Facility Administrator informed this LPA that they have been experiencing a large number of callouts. On 12/01/23, the Designated Facility Administrator informed this LPA that 2 new employees have been hired specifically for the NOC shift and that a third would be scheduled to be on call in order to prevent any staff member from working alone going forward. The preponderance of evidence standard has been met and the department found this allegation to be SUBSTANTIATED.

Regarding: Staff are not ensuring that residents take their medication(s) as prescribed while in care.


LPAs reviewed the Medication Administration Record (MAR) for 3 residents in care. LPA took photos for reference. Of the 3 records: the first was missing 28 entries, the second, 33 entries, and the last, 20 entries, with the latest being reviewed entered on 10/16/23. Total missing entries for three resident medication records for the month of October in 2023 was 81. There was also a post-it note dated 10/14/23 attached to R4’s record that stated: “Resident came back from the hospital with the doctor’s order to stop taking XXXXXX and XXXXXX, but there not on the MAR - faxed Dr.,” with the staff members initials. LPAs also heard R4 tell one
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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: 12/01/2023
NARRATIVE
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also heard R4 tell one of the NOC shift staff that they missed administering an earlier medication. Staff confirmed that they had, and immediately provided the medication. Based on observation, interview, and a review of records, the preponderance of the evidence standard has been met and the department found the allegation, “Staff are not ensuring that residents take their medication(s) as prescribed while in care,” to be SUBSTANTIATED.

According to the California Code of Regulations Title 22, deficiencies were observed and cited and may be found on the LIC 9099D pages.



A copy of this report was provided along with Appeal Rights.

Exit interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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: 12/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2023
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental 87465
(a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. The Licensee did not comply with the above regulation as evidenced by:
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The Licensee shall schedule a training to review MAR protocols with all MedTech Staff to ensure their understanding. Training will include a assessment tool. Licensee will submit facilitator, date, and time, and outline of training to kimberly.viarella@dss.ca.gov by 12/02/23. Signature sheets and copies of the assessment will be submitted to the same address by 12/22/23.
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By observation, interview and record review, the licensee did not ensure that the medication record was completed as evidenced by 81 missing entries. LPA also heard a resident remind staff that they were not provided with a medicated cream at the prescribes time. This posed/poses an immediate health and safety risk to residents in care.
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Type A
12/02/2023
Section Cited
CCR
87468.1(a)(2)
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Personal Rights (a) Residents in all residential care facilities for the elderly... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. The Licensee did not comply with the above regulation as evidenced by:



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Licensee sent the aggressor in the altercation mentioned for a new LIC 602 and new medications were prescribed. Going forward Licensee shall train staff to de-escalate and divert agitated residents in order to avoid future conflicts. Licensee shall submit facilitator, date, and time, and
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Based on a records review of the Modesto Police Department, the Licensee did not provide a safe environment for the residents in care as demonstrated by the altercation that took place on 10/04/23.
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outline of training to kimberly.viarella@dss.ca.gov by 12/02/23. Signature sheets and copies of the assessment will be submitted to the same address by 12/22/23.
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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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: 12/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2023
Section Cited
CCR
87625(b)(3)
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Managed Incontinence, 87625(b)(3)
(b) In addition to Section 87611... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors incontinence.

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Licensee has recently hired 2 new employees specifically for the NOC shift and shall schedule one person to be on call in order to ensure that there will be sufficient staffing to meet the needs of the residents in care. Licensee shall submit a schedule for the month of December to
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The licensee did not comply with the above regulation as evidenced by:
Based on observation,(facility malodorourus), a reivew of punch logs and interviews, the licensee did not keep residents dry and clean.
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kimberly.viarella@dss.ca.gov to reflect this new practice.
Type B
12/22/2023
Section Cited
CCR
87464(f)(4)
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87464 Basic Services shall at a minimum include: (4) Personal assistance and care as needed... with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... The Licensee did not comply with the above regulation as evidenced by:
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Licensee shall review shower log protocols and strategies for gaining compliance from residents with regard to all types of hygiene. Emphasis will be placed on logging, refusals, schedule changes, and carestaff noting strategies that have worked. Licensee shall submit facilitator, date of training, and signature sheets of participants by 12/22/23 to
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Based on observation, and interview Licensee did not ensure that resident's hygiene needs were being met. This LPA observed residents with long curling toenails wearing the same clothes repeatedly. LPA also learned that a resident had wore the same outfit several days in a row.
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kimberly.viarella@dss.ca.gov.
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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
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: 12/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
87307(a)(3)(C)
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87303 Personal Accommodations and Services (a) Living accommodations and grounds... provide comfortable living ... (3) Equipment... Licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

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Licensee shall buy additional bedding to meet the needs of the residents in care by 12/31/23 and will submit receipt to kimberly.viarella@dss.ca.gov.
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The Licensee did not comply with the above regulation as evidenced by:

The Licensee only had blankets in their House Supply for the 38 residents in care.
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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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7