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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507000307
Report Date: 03/15/2021
Date Signed: 03/15/2021 02:01:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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: 31DATE:
03/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Prithika SinghTIME COMPLETED:
02:00 PM
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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to conduct a case management on 03/15/2021 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the case management with Prithika Singh.

The purpose of the case management visit is to follow up on various concerns learned throughout a complaint investigation. The following concerns were discovered:

Heating and air: The facility has thermostats that control single and shared rooms. Shared room temperatures are set to meet the needs of both residents. If residents are cold, the facility provides additional blankets.

Facility Menu: The facility has a daily menu next to the dinning area and kitchen. The facility will provide residents with a weekly written menu upon request.

Call button: The facility has call buttons in residents room; in addition, the facility offers bell for additional call services. Facility administrator will provide a bell to residents who request one.

An exit interview was conducted, and a copy of this report was given to Prithika Singh via e-mail due to covid-19 precautions. Prithika Singh will return report via email.


SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (915) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021
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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