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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507000307
Report Date: 06/13/2022
Date Signed: 06/14/2022 04:07:30 PM

Substantiated


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
04/13/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20220413143539
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: 39DATE:
06/13/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Prithika SinghTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility has bed bugs.
The resident did not have access to her belongings.
The resident was moved into someone else's room.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit on June 13, 2022 at 10:30 a.m. to conduct an investiagion on the above allegations. LPA met with Administrator Prithika Singh and explained the purpose of today's visit.

Regarding the allegations facility has bed bugs. Based on interviews with Resident Responsible Parties and facility staff the facility does have bed bugs. LPA spoke with repsonsible party for three residents, and also facility Administrator Prithika Singh who stated there has been bed bug outbreaks at the facility recently. The facility staff discovered Resident 1's room had bed bugs on March 26, 2022 and did not move her into a separate room until after March 29, 2022 leaving Resident 1 in bed bugs for several days due to the facility Administrator not being present to assist with the situation. Therefore this complaint is SUBSTANTIATED.

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
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 4
Control Number 27-AS-20220413143539
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VINTAGE FAIRE RESIDENTIAL
FACILITY NUMBER: 507000307
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2022
Section Cited
CCR
87405(a)
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87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. The following requirment has not been met as evidenced by:
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Administrator will ensure the lead medication technician is trained to handle all Administrator responsibilities in her absence. Administrator will send proof of training to LPA by 06/28/2022 POC date.
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The facility staff discovered bed bugs in Resident 1's room and she was not moved into a separate room until days later due to the Administator not being at the facility to handle the situation which poses a potential health, safety, or personal rights risk to residents in care.
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Type B
06/14/2022
Section Cited
CCR
87468.1(a)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: The following requirement has not been met as evidenced by:
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Administrator will send proof to LPA by 06/14/2022 POC date that facility has hired a new exterminator that will treat bed bug outbreaks immediately
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Resident 1's room was not treated until weeks after bed bugs were initially discovered. Resident 1 was in a separate room from her belongings for more than 3 weeks due to the bed bug outbreak in her room which poses an immediate health, safety or personal rights risk to 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20220413143539
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VINTAGE FAIRE RESIDENTIAL
FACILITY NUMBER: 507000307
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The following requirement has not been met as evidenced by:
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Administrator will send proof to LPA by POC date 06/27/2022 of maintence director being on call including weekends to come into the facility and assist with outbreaks in a timely manner as needed.
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Resident 2's room has been infested with bed bugs three separate times starting in October 2021 to May 2022 which poses a potential health, safety or personal rights risk to 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20220413143539
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: VINTAGE FAIRE RESIDENTIAL
FACILITY NUMBER: 507000307
VISIT DATE: 06/13/2022
NARRATIVE
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Continued from 9099..


Regarding the allegation the resident did not have access to her belongings. Based on records reviewed and interviews with Administrator Prithika Singh residents are being displaced from their rooms for long periods of time without access to their belongings. The facility staff discovered Resident 1's bedroom had bed bugs March 26, 2022 and she was moved into a separate room days later. The exterminator did not come to heat treat or spray Resident 1's room until April 13, 2022. Resident 1 was displaced in a separate room away from her belongings for several weeks. Therefore this complaint is SUBSTANTIATED.


Regarding the allegation the resident was moved into someone else's room. Based on interviews and records reviewed the residents are being displaced from their rooms for long periods of time due to the facilities bed bug outbreaks. LPA interviewed the responsible party for Resident 2 who stated her mothers room had bed bugs three separate times starting in October 2021 and continued into May of 2022 despite being sprayed, and heat treated on multiple occasions. Resident 2 was moved into a separate room so her room could be sprayed and treated several times due to the reoccurring bed bug outbreaks at the facility. Therefore this complaint is SUBSTANTIATED.


The following deficiencies are being cited during this visit per Title 22 Regulations.

Exit interview conducted with Administrator Prithika Singh and a copy of this report was left at the facility along with appeals rights provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4