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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286802049
Report Date: 09/29/2021
Date Signed: 10/01/2021 10:01:05 AM

Document Has Been Signed on 10/01/2021 10:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:VINTAGE HOUSEFACILITY NUMBER:
286802049
ADMINISTRATOR:ROA, FRANCISCOFACILITY TYPE:
740
ADDRESS:2541 VINTAGE STREETTELEPHONE:
(707) 265-8652
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 4DATE:
09/29/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Catalina Sanchez & Renee Johnson - staffTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Case Management - Annual Continuation Infection Control inspection to this facility and met with staff Catalina Sanchez & Renee Johnson. Facility has 4 residents present with 1 resident under Hospice care at this time.
During facility tour on 9/29/2021 with staff Renee Johnson, facility was found to be clean and at a comfortable temperature. Bedroom 4 has a long hospital bed that per staff will be removed to allow residents to exit through the door if needed in case of emergency. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 9/2021. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. There was a supply of PPE available. Facility has a closet door and two window shades in the garage that facility will be installing on facility. Department is requesting submission of pictures showing that bed has been removed - smaller bed in place is OK, closet door and window shades installed by 10/6/2021. In addition, documentation below requested by 9/27/2021 still pending to be submitted to the Department:
LIC 308 Designated Administrator
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Resident’s
Copy of Administrator Certificate
Copy of Liability Insurance
No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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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