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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603317
Report Date: 05/20/2025
Date Signed: 05/20/2025 03:55:44 PM

Document Has Been Signed on 05/20/2025 03:55 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VINE RESIDENCEFACILITY NUMBER:
198603317
ADMINISTRATOR/
DIRECTOR:		LOPEZ, LORRAINEFACILITY TYPE:
740
ADDRESS:1405 E. VINE AVETELEPHONE:
(626) 890-7634
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 6DATE:
05/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Lorraine Lopez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted the unannounced required annual inspection. LPA arrived unannounced and met with Caregiver Sandra Portillo Alvarde. Administrator, Lorraine Lopez, arrived shortly thereafter to assist. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. 6 Ambulatory, of which 5 may be non-ambulatory and 1 may be bedridden. Hospice Waiver for 6 residents. Currently, there are two (2) residents are on hospice.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

1. Infection Control: Facility has an updated infection control plan in place. The facility staff and residents continue to practice the hand washing and disinfecting the facility each shift. The facility has sufficient PPE supplies.

2. Operational Requirement: The facility has approved for 5 non-ambulatory and 1 may be bedridden currently there's only one resident is bedridden which is within the fire clearance requirement. LPA observed current Liability insurance in place. The facility has a dementia care plan to accept or retain residents with dementia.

3. Physical plant and Environmental Safety: The facility is a single-story house and located around the neighborhood area. The facility include living room, staff break room with a divider, six residents’ bedrooms, three residents’ bathrooms, kitchen, dining area, family room and attached garage. Laundry washing machine and drying machine is in the garage.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VINE RESIDENCE
FACILITY NUMBER: 198603317
VISIT DATE: 05/20/2025
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3. Physical plant and Environmental Safety: Each resident has one bed, one chair, one drawer and required furniture and beddings and sufficient lighting and closet space. All three resident's bathrooms are clean, sanitary and in a good working condition. The hot water temperature in all three bathrooms were tested between 113.7- and 114.1 degrees F which is within Regulations. The bathroom has the required non-skid mat and grab bar in the shower. There are two fireplaces with one in the living room and one in the family room is adequately screened and secure. All the appliances in the kitchen are working properly. The sharp knives and utensils are stored and locked in the kitchen drawer. All the dish soap are stored and locked under the sink. All cleaning supplies and chemicals are stored and locked in the cabinet located in the garage. All the extra personal hygiene products are stored and locked in the garage cabinet. The facility has a telephone on the premises. The carbon monoxide detector are working well in the facility. The facility has a pool in the backyard and it's locked and gated with a fence. The passageway, walkway and patio are free of obstruction. Fire Extinguisher located in the kitchen is fully charged and was last inspected on 04/21/2025.

4. Staffing: Facility has a sufficient staffing to provide care and supervision to the residents. Each facility staff has an updated First aid and CPR certificate. The NOC shift staff has an updated facility emergency planned procedure training.

5. Personal Records-Training: All staff are over 18 years old, fingerprint cleared and associated with the facility. LPA reviewed the admin and three (3) staff files which includes: personnel record, Health Screening, TB test result, Employee Rights, ongoing staff training and medication management training. The facility administrator is Lorraine Lopez and certificate expire 11/13/2025 and she has the required training hours as a qualified administrator.

6. Resident's Right: The RCFE complaint poster and personal right poster posted on the wall in the living room. The facility has internet service and provide at least one internet access device such as computer or tablet and equipped with video conferencing and residents can have meetings with their family or their physician if needed.

7. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VINE RESIDENCE
FACILITY NUMBER: 198603317
VISIT DATE: 05/20/2025
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8. Food Service: The facility has sufficient food supply including minimum 2 days perishable and 7 days non-perishable. The facility kitchen is clean and well-kept and in a operable condition. The food are properly stored in the refrigerator to avoid cross contamination. No resident required a modified diet that's prescribed by the doctor. Facility staff will chop the food for resident to prevent choking.

9. Incidental Medical and Dental: The facility will arrange residents' medical and dental appointment if needed. All the resident's medication are centrally stored and locked in the cabinet in the hallway. LPA inspected all six residents’ medication and they all seemed accurate and updated and they all have 30 days’ supply of medication.

10. Resident Record-Incident Reports: All the resident file in the facility has all the required documents including emergency identification and information form, signed admission agreement, updated medical assessment, Ambulatory Status, TB test results, Resident Appraisal, Personal Rights, Centrally Stored Medication Destruction Record, Safeguards for Personal Property/Valuables, functional capability assessment, pre-appraisal and appraisal / needs and service plan, and medication list in the file.

11. Disaster Preparedness: The facility has an updated emergency Disaster plan in place. The facility has at least two appropriate alternative shelter location. The last disaster drill was conducted on 03/19/2025. The emergency exit plan and telephone number posted on the wall in the living room.

12. Resident with Special Health Needs: Currently the facility has two residents on hospice and one bedridden and it's within the requirement and fire clearance. All staff does have the required training for the hospice and dementia residents. The hospice residents has the updated information in their hospice record along with the resident's file.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit Interview conducted and a copy of the report was provided to the Administrator, Lorraine Lopez.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
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