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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507000307
Report Date: 02/21/2024
Date Signed: 02/21/2024 03:31:03 PM


Document Has Been Signed on 02/21/2024 03:31 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 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:
02/21/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Prithika SinghTIME COMPLETED:
03:40 PM
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On 2/21/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for the purpose of a health and safety check. LPA Jensen met with Administrator Prithika Singh and explained the purpose of today's visit. The Department is conducting health and safety checks to monitor the facility in the areas of care and supervision, staffing, buildings and grounds and resident hygiene.

The Administrator handed LPA Jensen a request for a hospice waiver increase for review. LPA Jensen requested the staff schedule as well as records documenting hours worked. LPA Jensen also requested pest control service records.

LPA Jensen toured the facility including the kitchen, reading room, a resident room, common areas and hallways. No deficiencies were observed. LPA Jensen viewed the supply of linens and bedding and determined it to be sufficient. LPA Jensen toured the grounds and observed the grounds to be maintained with all pathways to be free of obstruction. There was outdoor furniture available to clients. LPA Jensen engaged with several clients during the course of the visit. The clients observed during the course of this visit appear have had their grooming needs met.

LPA Jensen interviewed the Administrator who advised the facility is currently fully staffed and they have extra staffing available if there are call outs. The Administrator advised they have been experiencing issues with the company email system through Covenant Care California Inc. and also with faxing. LPA Jensen is requesting incident reports be sent by regular mail through United States Post Office (USPS) until the issue is resolved. Technical assistance is being provided on reporting requirements.

LPA Jensen and the Administrator discussed emergency plans and disaster protocol. There is a resident roster in the disaster binder. The facility is planning to conduct a disaster training refresher in the near future. No citations were issued. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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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