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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507000307
Report Date: 05/09/2024
Date Signed: 05/10/2024 12:48:55 PM

Unsubstantiated


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
02/26/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240226102140
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: 34DATE:
05/09/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Joyce PrasadTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not ensure facility was kept free of pests
Staff did not safeguard resident's personal items
INVESTIGATION FINDINGS:
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On 5/9/24 at approximately 10:00am, Licensing Program Analyst (LPA) Maja Jensen arrived at facility to continue an investigation in to the above listed allegations. LPA Jensen met with Business Office Manager, Joyce Prasad, and explained the purpose of the visit.

Staff did not ensure facility was kept free of pests
On 10/19/23, the facility was cited for “repeated observations and treatments for active bed bugs in the facility” with a plan of correction that required the facility, in part, to “create a policy specific to the elimination of bedbugs and the maintenance of a bed bug free facility.” After this citation was issued, the facility has had pest control treatments based on the service records reviewed. LPA Jensen also interviewed 10 residents and 9 staff members. All residents stated bed bugs are not a problem or no longer a problem. All current staff members also stated that bed bugs are not a problem or no longer a problem and 1 former staff member stated that the facility has bed bugs. Based on the pest control service invoices reviewed and the interviews conducted the allegation UNSUBSTATIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
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 2
Control Number 27-AS-20240226102140
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: 05/09/2024
NARRATIVE
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Staff did not safeguard resident's personal items

LPA Jensen interviewed 10 residents and 1 resident family member. The majority of residents stated they have had no issues with their personal items missing or not safeguarded. 1 of 10 residents stated that his clothing disappears and reappears on occasion. 1 of 10 residents stated that her door remains locked to prevent any items from disappearing due to a resident that has a habit of wandering into other client’s rooms. LPA Jensen interviewed a housekeeping staff member who explained that only a single resident’s laundry is washed per load. All clothing that can labeled is labeled. After clothing is washed and dried it is hung up and organized based on room number. LPA Jensen reviewed facility theft and loss policy as well as the facility training records for theft and loss which state staff are trained on the theft policy annually. The theft and loss policy states that upon admission, an inventory of personal property will be completed. The list must be verified by the resident or responsible party. Items on the list will be engraved or marked for identification and the facility is not liable for items not on the list and that the facility will provide a locked drawer at the request of and at the expense of the resident. While it is possible that at some point an item was inadvertently misplaced the allegation of “staff did not safeguard resident’s personal items” is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

An exit interview was conducted and a copy of this report and appeal rights were provided.

LPA Jensen returned on the morning of 5/10/24 to provide report due to technical difficulties with printer

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2