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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507000307
Report Date: 07/09/2024
Date Signed: 07/09/2024 03:58:09 PM


Document Has Been Signed on 07/09/2024 03:58 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: 33DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joyce PrasadTIME COMPLETED:
04:15 PM
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On 7/9/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual inspection. LPA Jensen met with Administrator Prithika Singh and explained the purpose of today's visit. The Administrator holds a current certification # 7009678740 good through 10/20/2024.

LPA Jensen toured the grounds and observed all paths to be free of obstruction. There are shaded areas and patio furniture available for resident use. All window screens appeared to be in good repair. A large branch that had fallen from a tree on the property was on the ground near resident rooms. The branch was not creating a hazard. LPA Jensen provided technical assistance to the Administrator regarding monitoring the health of the tree as it is in proximity to resident rooms.

LPA Jensen toured the facility interior including the common areas, resident rooms and kitchen. The fire extinguisher and Ansul system was last serviced on October of 2023 and is in compliance. The facility maintains a first aid kit that is complete. No medications or toxins were observed to be accessible to residents in care. The kitchen appeared sanitary. A 2 day supply of perishable food and 7 day supply of non-perishable food was available. LPA Jensen observed numerous food items in the pantry that is ordered in bulk to be missing expiration dates including canned fruit and vegetables, ketchup and dry good such as flour. Technical assistance regarding food storage was provided.

LPA Jensen toured 10 resident rooms and observed all to have the required furniture. LPA Jensen observed a dresser that was broken, a bed spread that was torn, a chair that was torn and some carpet stains. Technical assistance was provided. The water temperature was measured in a resident bathroom at 118 degrees Fahrenheit which falls within the required range of 105-120 degrees.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/09/2024
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LPA Jensen interviewed 5 residents, all of whom stated they are satisfied with the care they are receiving. LPA Jensen reviewed 5 resident files and observed them to be complete. The needs and service plans for residents were observed to be updated and in compliance. LPA Jensen reviewed 5 staff files and determined them to be complete. The facility admits residents participating in the P.A.C.E. program through WellBe health and as such is subject to the Home and Community Based Services final rule. Technical assistance was provided. The inspection tool was used during the course of this visit. LPA Jensen left the facility from 12pm to 1pm for a meal period.

The Licensee will email LPA Jensen an updated LIC 500 and current liability insurance.

No deficiencies are being cited. An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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