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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507000307
Report Date: 07/08/2025
Date Signed: 07/08/2025 03:50:54 PM

Document Has Been Signed on 07/08/2025 03:50 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/
DIRECTOR:		PRITHIKA B SINGHFACILITY TYPE:
740
ADDRESS:3620-A DALE ROADTELEPHONE:
(209) 521-1798
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 49CENSUS: 44DATE:
07/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Prithika Singh, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 7/8/24 Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required one year annual inspection. The LPA met with and interviewed Administrator Prithika Singh and explained the purpose of today's visit. The Administrator accompanied the LPA on a tour of the facility.

The LPA toured the facility interior, including the lobby, small and large dining rooms, and resident rooms. The lobby is the main common area for residents. Residents were gathered watching a movie and eating ice cream. There were several couches and tables in good repair in this room. Then the LPA toured the small and large dining rooms off the lobby. The dining rooms contained four and six tables respectively, with enough seating for residents. The LPA inspected ten bedrooms. The bedrooms contained the required furniture in good repair and are clean and odor-free. Each bedroom has a private bathroom with grab bars. The LPA measured the temperature of the hot water in a resident bathroom; the water was one hundred and sixteen degrees Fahrenheit. The windows and sliding glass doors were in good repair.

The LPA toured the Kitchen. The kitchen was clean, organized, and odor- and -pest free. The LPA inspected the pantry and freezers and observed a seven-day supply of nonperishable food and a two-day supply of perishable food. Food is stored properly and rotated on a weekly basis. The stove hood was last serviced in November 2024 and was clean.

The LPA toured the hallways. There were fire extinguishers in several locations in the hallway, as well as the kitchen. There was a smoke detection system that automatically closes several doors in the common areas, sounds an alarm, and indicates which zone a fire is in. There is an overhead sprinkler system. The smoke detectors, sprinkler system, and fire extinguishers were serviced by Jorgensen Co. of Modesto on 11/23/2024. Required notices were posted in the hallways, including personal rights, emergency disaster plan, and ombudsman contact information. The thermostat in the common areas was set at 71 degrees.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/08/2025
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The LPA toured the locked central medication room. Resident files are kept in this room. Medications were stored in their original packaging with intact labels and organized by resident.. The facility used an electronic medical administration record.

The LPA toured the grounds The lawn wasgreen and manicured. The concrete walkways were free of obstruction. There was a shaded seating area outside the small dining room with a pavilion, table and chairs, and large tree.

The LPA interviewed six residents. Residents reported that their rooms are cleaned daily and that they appreciate having a private bathroom. The LPA reviewed three resident and three staff files and observed them to be complete. The facility conducted quarterly fire drills in the last year in the AM and PM shifts with all staff.

The LPA requested that updated copies of these documents be submitted to Licensing by 5:00 PM on 07/16/2025. These documents can be emailed to LPA at ellen.lindstrom@dss.ca.gov.

(1) LIC 308 Designation of Facility Responsibility


(2) Copy of a current Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Liability Insurance
(6) LIC 500 Personnel Report
(7) LIC 309 Administrative Organization

As a result of this inspection, no deficiencies were cited. The facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6.

An exit interview was conducted with the Administrator, to whom a copy of this LIC809 report was provided. Their signature below confirmed receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
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