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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507000307
Report Date: 03/15/2021
Date Signed: 03/15/2021 02:05:04 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2020 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200604150206
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: 30DATE:
03/15/2021
UNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Prithika SinghTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not providing basic services to residents.
Facility failed to administer medication to residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Avelina Martinez contacted the facility via telephone to deliver investigation findings 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 allegations with Prithika Singh.

Throughout the course of the investigation, LPA Martinez toured the facility, conducted interviews and reviewed facility documents. During the investigation, residents reported they were satisfied with the care they are receiving. Moreover, Resident 1 (R1) reported submitting complaints to the administrator in the past. R1 reported all complaints were corrected in a timely manner, and is now satisfied with the care. Resident 2 (R2) reports receiving medication on time, and no issues with showering services. Resident 3 (R3) reports receiving medication on time, and has no concerns about the care. Resident 4 (R4) reports receiving showering services, and is satisfied with the showering care.

Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.

An exit interview was conducted with Prithika Singh via telephone, and a copy of this report was provided to Prithika Singh via email, and an electronic email read receipt confirms receiving these documents.

Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
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