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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286802049
Report Date: 09/22/2022
Date Signed: 09/22/2022 12:09:23 PM

Document Has Been Signed on 09/22/2022 12:09 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Francisco RoaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 09/22/2022 to conduct a Required - 1 Year inspection. This inspection was focused on the infection control practices and procedures of this facility. LPA was initially greeted by staff. Administrator, Francisco Roa arrived shortly.

LPA toured building and grounds which were clean and in good repair. Exits and walkways were free from obstructions. Facility has a total of 4 bedrooms, 2 of which are shared. There are currently 4 residents in care. Current census allows for isolation of residents if necessary. Resident bathrooms have necessary grab bars and non-slip mats. Resident bedrooms were furnished per regulation. LPA observed operational CO and smoke detectors throughout the facility. Facility had a sufficient supply of perishable and non-perishable food. Toxins were kept locked and secured. Medications were centrally stored and inaccessible to residents in care. Facility had a supply of extra linens and towels for residents. LPA reviewed 3 staff files and 3 resident files. LPA and administrator discussed ongoing training requirements for staff. LPA and administrator discussed when it is necessary to request updated physician's reports. All staff and residents are fully vaccinated. Administrator is working with public health to schedule the third booster shot.

LPA is requesting the following documents be submitted within 30 days of the inspection:

LIC 500 Personnel Report
LIC 610 Emergency Disaster Plan
LIC 9020 Resident Roster
LIC 308 Designation of Facility Responsibility
Evidence of Liability Insurance

No deficiencies cited during today's inspection. Exit interview conducted with administrator and a copy of this report printed for the facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
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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