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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507000307
Report Date: 06/24/2024
Date Signed: 06/24/2024 11:39:32 AM

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
06/10/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240610115421
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:
06/24/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Prithika SinghTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff mismanages resident's medications.
INVESTIGATION FINDINGS:
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On 6/24/24 at approximately 11:00 am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegation. LPA Jensen met with Executive Director Prithika Singh and explained the purpose of today's visit.

During the course of the investigation LPA Jensen inspected the medication room and interviewed the Administrator, a medication technician (S1) and housekeeping staff (S2). The Administrator advised that the medication technicians are required to watch residents take their medication in order to ensure they are taking them when administered. The medication technician interviewed stated that some resdients are watched to ensure that they take their medication and housekeeping staff stated that she found medication in a resident room last month when cleaning. Based on the interviews conducted staff are not following medication administration protocol as required by facility policy resuting in some resdients not taking medication as prescribed therefore the allegation is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.
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: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
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-20240610115421
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: 06/24/2024
NARRATIVE
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A citation is being issued pursuant to the California Code of Regulations (CCR) Title 22, Division 6. A civil penalty is also being assessed for repeat violations.

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: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240610115421
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: 06/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2024
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care
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The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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The Administrator agrees to develop a plan to come in to compliance with regulatory requirements related to medication administration and send the plan to LPA Jensen by 6/25/24.
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Based on interviews conducted staff are not following facility policy on medication administration which has resulted in medication not being taken as prescribed. This poses an immediate risk to the health, welfare 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: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3