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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
507000307
Report Date:
02/14/2024
Date Signed:
02/14/2024 04:11:37 PM
Document Has Been Signed on
02/14/2024 04:11 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
SACRAMENTO SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
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:
37
DATE:
02/14/2024
TYPE OF VISIT:
Case Management - Health Checks
UNANNOUNCED
TIME BEGAN:
03:25 PM
MET WITH:
Joyce Prasad-Administrative Assistant
TIME COMPLETED:
04:25 PM
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On 2/14/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a health and safety visit. LPA Jensen met with Joyce Prasad and explained the purpose of the visit. Joyce explained that the Administrator was out due to illness and that she was in charge however she was unable to stay due to having a prior commitment. LPA Jensen was referred to the Medication Technician who was temporarily in charge.
LPA Jensen interviewed 2 staff members and 1 resident. LPA Jensen toured a double occupancy resident room and the facility dining room. Technical assistance is being provided in the area of Administrator Qualifications and Duties. LPA Jensen did not have access to all facility records such as personnel files or building and maintenance records. LPA Jensen will return at a later date when there is an Administrator or designee present.
An exit interview was conducted and a copy of this report was provided to the Medication Technician.
SUPERVISOR'S NAME:
Lisa Rios
TELEPHONE:
(916) 969-9685
LICENSING EVALUATOR NAME:
Maja Jensen
TELEPHONE:
(916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE:
02/14/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/14/2024
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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