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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507000307
Report Date: 02/20/2025
Date Signed: 02/20/2025 04:32:12 PM

Document Has Been Signed on 02/20/2025 04:32 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: 37DATE:
02/20/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Prithika Singh, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 02/20/25, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility regarding a case management for an elopement. LPA Campbell met with Prithika Singh, Administrator and explained the purpose of the visit.

This case management is regarding R1 who eloped on 02/17/25. Per the Unusual Incident Report (UIR) submitted on 02/18/2025, R1 was last seen by S1 at 7:40 pm on 02/17/2025. Staff noted he was missing when the door alarm sounded. After searching the facility premises, the Modesto Police Department (MPD) were called at 8:43 pm on 02/17/25 and a report was taken for case #MP25004110.

During LPA Campbell's visit, the administrator reported that St. Joseph's Hospital in Stockton contacted the facility to report that R1 had been found and was receiving treatment. Because R1 was now in Stockton, the Stockton Police Department (SPD) was contacted so that they could conduct a visit at the to confirm R1 could be taken off 'Missing Person" status. LPA Campbell asked the Administrator to write a UIR to share R1's current status. Because R1 had missed two of his dialysis appointments, the hospital would be keeping R1 for up to three days. This will provide time for Welba Health, the hospital and the facility to work together to find a new placement or for the facility to create plan to support R1 if he needs to return to the Vintage Faire.

Prior to this incident, Administrator Singh submitted several UIR's regarding a change in R1's behavior. LPA Campbell consulted with Administrator Singh regarding steps to avoid future elopements , how the eviction procedure may help when there is a change in condition and the need for reappraisals.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 02/20/2025 04:32 PM - It Cannot Be Edited


Created By: Renee Campbell On 02/20/2025 at 02:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VINTAGE FAIRE RESIDENTIAL
FACILITY NUMBER: 507000307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2025
Section Cited

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1569.312 Basic services requirements.
Every facility ... shall provide ... the following basic services:(d) Being aware of the resident's ..whereabouts...(e) Monitoring . activities of the residents...to ensure their general health... This requirement is not met as evidence by:
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Based on documents reviews and interviews, the facility was not aware of the residents whereabouts and could not monitor activities of the resident to ensure their general health.
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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 Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 02/20/2025
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 LPA Campbell also reminded the administrator that the facility had a responsibility to supervise and care for residents until an more appropriate placement can be found by working with the hospital and Welbe Health (placement agency).

Based on LPA Campbell's record reviews and interviews which were conducted, the facility was unable to supervise R1 and be aware of R1's whereabouts.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. 
An exit interview was conducted, and copies of the report and appeal rights left. 
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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