502701602-5-16-2025-27-AS-RCAL-DGQRCZ-20250516125511

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701602
Report Date: 05/16/2025
Date Signed: 05/16/2025 12:55:22 PM

Document Has Been Signed on 05/16/2025 12:55 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	VINTAGE FAIRE RESIDENTIAL		FACILITY NUMBER:	502701602
ADMINISTRATOR/ DIRECTOR:	SINGH, PRITHIKA BANDHANA		FACILITY TYPE:	740
ADDRESS:	3620-A DALE ROAD		TELEPHONE:	(949) 540-1720
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY: 49		CENSUS: 44	DATE:	05/16/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Administrator Prithika Bandhana		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/16/2025, at 9:15 am, Licensing Program Analyst (LPA), Renee Campbell arrived unannounced to conduct an inspection to the above facility for the purpose of a pre-licensing evaluation. This pre-licensing is for Change of Ownership (CHOW) to Deer Tail Living Inc. DBA Vintage Faire Residential. LPA met with Administrator Prithika Singh, Francis Santillian, Marketing and Eric Olson with Marketing and explained the purpose of the visit. LPA Campbell inspected the physical plant of the facility to ensure compliance of Title 22 regulation. LPA observed 5 random resident units, the activity room, dining room, kitchen, laundry, and outdoor areas. The Facility has a 49-resident capacity for Assisted Living residents. The facility is a one-story building located in a residential neighborhood. Outdoor passageways, walkways, driveways, and steps are free from obstructions. LPA Campbell did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bodies of water were not observed at this time. Resident Bedrooms: LPA inspected 5 resident units. Each unit is fire cleared for non-ambulatory residents. The resident apartments/units are spacious and will easily accommodate the residents furnishings. The inspected resident units were observed to be furnished with adequate storage for resident belongings.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

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 4

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)

Page: 2 of 4

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: 502701602
	VISIT DATE: 05/16/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Bathroom: Each resident unit contains a private bathroom. All bathrooms inspected have working toilets, wash basins and full baths have showers. There are grab rails next to both the toilets and the showers as well as nonskid flooring.
Toxins and Chemicals: Toxins and chemicals for cleaning are properly stored, locked, and inaccessible to residents in care. .
Water temperature: Water temperature in 2 randomly selected bathrooms (in a resident units) were measured at 117.9 in room #7 and 116.1 degrees F in room #8.

Food Service and Kitchen: The kitchen area and dining area were inspected and observed to be in good repair. Knives, cutlery and other sharp kitchen utensils are locked and inaccessible to residents. The food supply was adequate and stored in kitchen refrigerator and walk-in pantry and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items. The date of purchase was written on food items in the refrigerator and freeezer. Stove burners and oven were observed to be in good repair. Temperature in freezer was observed to be within regulatory standard -1.3 degrees Fahrenheit for the freezer. Menu was observed outside of the dining rooms and available for viewing to residents in care. LPA Campbell observed admission sheets over the food prep area to inform staff of new resident's dietary needs.

Smoke Detectors/Carbon Monoxide: Each inspected resident units were observed to have a smoke detector and carbon monoxide detectors. Additionally, facility is equipped with sprinkler system. Smoke detectors are hardwired and interconnected, and they are fully operational. Facility conducts quarterly smoke alarm testing. The most recent test occurred 02/18/2025 and was passed successfully.

Medications and First-Aid Kit: Resident medications were observed to be stored in the medication room and locked and inaccessible to residents in care. The first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in the locked medication room. A first aid kit is also kept in the Administrator's office and available for staff use but inaccessible to clients.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 502701602
	VISIT DATE: 05/16/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facility, Residents & Staff Files: Facility will not be handling cash resources of residents. Records of staff and residents are stored in a locked room and accessible to staff. LPA Campbell reviewed 4 resident files that were found to be complete.

Component III: Conducted at the Pre-Licensing visit, on 05/16/2025 at Vintage Faire Residential and information provided about how to operate the facility within substantial compliance.
Pre licensing is complete and this facility has no deficiencies.

An exit interview was conducted with Administrator Prithika Singh. A copy of this report was provided.

If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4