331881452-9-9-2024-18-AS-JARA-D8XPDW-20240909111410

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881452
Report Date: 09/09/2024
Date Signed: 09/09/2024 11:14:20 AM

Document Has Been Signed on 09/09/2024 11:14 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SENIOR ASSISTED LIVING AT VINTAGE RESERVE LLC		FACILITY NUMBER:	331881452
ADMINISTRATOR/ DIRECTOR:	BARROSO, MARIBEL		FACILITY TYPE:	740
ADDRESS:	40147 GRENACHE COURT		TELEPHONE:	(951) 719-0270
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY: 6		CENSUS: 5	DATE:	09/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Staff, Samira Purmul		TIME VISIT/ INSPECTION COMPLETED:	11:20 AM

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with, Staff, Samira Purmul who were informed of the purpose of the visit. At the time of the visit there was (3) staff and (5) residents present.

The facility is a one story home with (6) bedrooms and (3) bathrooms with attached garage. No pools or firearms are being kept at the facility.

Infection Control: The LPA observed hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were observed in good condition. The outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SENIOR ASSISTED LIVING AT VINTAGE RESERVE LLC	FACILITY NUMBER: 331881452
	VISIT DATE: 09/09/2024

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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff schedule showing adequate staff coverage. Required postings were found in the facility. The listed administrator, possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All resident medication were locked in a medication cart. LPA reviewed medications for clients and found all medication listed on MARS and accounted for. All medications had the required labeling and doctor's orders.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The last conducted fire drill was conducted on 8/17/2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit with all required items.

No deficiencies were cited at the time of the visit. An exit interview was conducted with Licensees,Pedro Barroso over the phone, and Samira Purmul in person.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC809 (FAS) - (06/04)

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