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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507000307
Report Date: 05/23/2024
Date Signed: 05/23/2024 04:33:31 PM

Substantiated


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
03/18/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240318103436
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:
05/23/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Prithika SinghTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff do not meet resident's dietary needs.
INVESTIGATION FINDINGS:
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On 5/23/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Administrator Prithika Singh and explained the purpose of today's visit.
During the course of this investigation LPA Jensen reviewed 5 resident files. 1 of 5 resident files contained a physician report that states Resident 1 (R1) requires a soft mechanical diet. LPA Jensen interviewed the kitchen manager who stated they were not aware of any dietary restrictions for R1. LPA Jensen inspected the kitchen and observed postings in the kitchen that consisted of lists of residents who require chopped food, diabetic diet and foods specific people would like to avoid. According to kitchen staff those are the only dietary restrictions. Based on record reviews, interviews and LPA Jensen's kitchen observations, the allegation of "staff do no meet resident's dietary needs" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. A deficiency is being cited pursuant to the California Code of Regulations (CCR). An exit interview was conducted and this report, appeal rights and a confidential names list was given
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
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 3
Control Number 27-AS-20240318103436
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
CCR
87555(b)(7)
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Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not as evidenced by:
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Facility kitchen staff was immediately informed that R1 requires a modified diet. The Licensee agreed to audit all resident files to ensure any dietary restrictions are being adhered to.
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Based on LPA Jensen's interview with kicthen manager and record review, R1 was not receiving a soft mechanical diet as ordered by the physician. This poses an immediate risk to the health, safety and personal rights of residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC9099 (FAS) - (06/04)
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