Vine Hill Senior Living

Type of visit: Case Management - Annual Continuation

At approximately 1:35 PM, Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to continue a required 1-year annual inspection and was greeted by Caregiver Princess Bernales. Administrator Delilah Ardiente was contacted via phone and arrived at approximately 2:30 PM. Facility is a Residential Care Facility for the Elderly (RCFE) with three (3) residents in care. Facility has a Hospice waiver for four (4), with zero (0) Hospice residents currently in care, and is approved for four (4) non-ambulatory residents. Physical plant walk-through conducted 10/3/2025. At approximately 1:50 PM LPA conducted a review of three (3) resident records. All required documentation present. At approximately 2:10 PM LPA conducted review of four (4) staff records. All required documentation present. At approximately 2:50 PM LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored and locked. Facility conducts quarterly disaster drills, and the most recent drill was conducted 10/25. LPA observed facility's emergency disaster plan which was last updated 10/25. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Nov 6, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 1:35 PM, Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection and was greeted by Caregiver Princess Bernales. Administrator was contacted via phone and was unable to attend, Princess Bernales was designated to sign and receive report. Facility is a Residential Care Facility for the Elderly (RCFE) with three (3) residents in care. Facility has a Hospice waiver for four (4), with zero (0) Hospice residents currently in care, and is approved for four (4) non-ambulatory residents. At approximately 1:55 PM, LPA initiated a tour of the facility with Caregiver and observed the following: Facility is a one (1) story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were last inspected 2/25. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Water temperature measured 105.5 degrees F, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food, as well as an emergency water supply. Food was found to be stored in a safe manner with open items covered. There is a shaded seating area in the backyard with outdoor space for activities. Facility has an internet access device and internet available to residents in care, and the phone was tested and operational during today's inspection. The annual inspection will be completed by the Department at a later date. No deficiencies cited. Exit interview conducted with Caregiver, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Oct 3, 2025

Type of visit: Post Licensing

At approximately 2:30PM, Licensing Program Analysts (LPAs) Julie Florio and Ethel Contreras arrived unannounced to conduct a Post Licensing Continuation inspection and met with Bertrand Mendola, Designated Responsible Party (DRP). Licensee and new Administrator were unable to attend today's visit but participated via telephone for the duration of the visit. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. LPAs immediately toured facility and observed garage is being used as staff lounge. Licensee stated that no one is living or sleeping there. Licensee states the facility conducts quarterly disaster drills but was unable to provide documentation proof of any drills completed, (see LIC809D). Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed Personal Rights poster has been placed in the main entry way of the facility. Licensee provided LPAs with documents for change of administrator to appoint a new facility administrator. LPAs observed staff files with the required proof of training and resident files with the required documents per regulation. LPAs reviewed medication records which were found not maintained in compliance with regulation as evidenced by LPAs observation of medications not listed on the Centrally Stored Destruction Log (See LIC809D). Facility does not handle P&I. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC610D Emergency Disaster Plan (updated) Continued on LIC809C... Continued from LIC809... Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights were given. Exit interview conducted with DRP whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Apr 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: May 30, 2025

Emergency Plans: A facility shall conduct a drill at least quarterly for each shift….Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement has not been met as evidenced by: Based on LPAs observation of medications not listed on the Centrally Stored Destruction Log for R1 which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 28, 2025

Plan of correction: Licensee agrees to submit self certification that all Centrally Stored Medication Destruction Records have been brought into compliance and will ensure facility operates in compliance moving forward to CCL by POC due date 5/30/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(a)(6) · Plan of correction due date: May 30, 2025

Incidental Medical and Dental Care: When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement has not been met as evidenced by: Based on licensee was unable to provide documentation proof of any drills completed which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 28, 2025

Plan of correction: Licensee to submit proof of disaster drills completed to CCL by POC due date 5/30/2025

Type of visit: Post Licensing

On 04/10/2025, at approximately 1:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced at the facility to conduct a post-licensing inspection and met with Safir Rezzoug, Licensee. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care, all of whom were present during today's inspection. Facility has a Dementia Care Plan, a Hospice waiver for four (4), and is approved for four (4) non-ambulatory residents. At approximately 1:45 PM, LPA initiated a tour of the facility with Licensee and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured at 132 degrees F which in outside the allowable range of 105 to 120 degrees F per Title 22 regulations. Licensee agreed to turn down the water heater and track the facility's water temperatures over the next 10-days to ensure the facility has been brought back into compliance with regulation. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA advised Licensee to increase the amount of fresh fruit and vegetable available to residents in the facility. Licensee agreed. LPA informed Licensee that no staff shall sleep in the garage area of the facility as it is not a cleared space for staff sleeping quarters. Licensee conveyed understanding of this and agreed to comply. LPA advised Licensee that the required personal right poster and a copy of the current administrator's active certificate shall be posted in a conspicuous area of the facility. Licensee agreed to bring the facility into compliance with regulation. At approximately 2:00 PM, LPA began file review. LPA reviewed five (5) staff files and one (1) resident file. LPA observed three (3) of five (5) staff files missing proof of initial 40 hours of training, four of four staff file missing proof of initial medication training, and one (1) staff file missing proof of first aid training. Continued on LIC809C... Continued from LIC809... LPA observed Resident 1 (R1) missing the required annual physician's repot and updated appraisal needs and services plan. LPA informed Licensee that all required forms shall be signed by staff, resident, or responsible party to remain in compliance with regulation. LPA will return at later date to complete this post-licensing inspection and may issue citations at that time. Licensee informed LPA that they would like to change the facility administrator to himself. Required Change of Administrator Documents: LIC 308 (Designation of Facility Responsibility) Active and Current Administrator Certificate First Aid Certificate LIC 500 (Personnel Report) LIC 501 (Personnel Record) LIC 503 (Health Screening Report - personnel) Proof of Negative TB test LIC 9182 (Criminal Record Exemption Transfer Request) LIC 508 (Criminal Record Statement) Copy of Driver's License or Passport that is not expired Statement signed by Licensee requesting Change of Administrator Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: Proof of Liability Insurance (Updated) LIC308 - Designation of Facility Responsibility Current Administrator Certificate No deficiencies cited during today's inspection. Exit interview conducted with Licensee, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 10, 2025

Type of visit: Prelicensing

At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, for the purpose of conducting a pre-licensing inspection and met with current Administrator Christina Ramirez. This pre-licensing inspection is being conducted due to a change of ownership. Applicant was not present at the time of this inspection. LPA contacted applicant and left a message that LPA was at the facility. Fire Clearance has been approved for a capacity of 6 residents; 4 of which may be non-ambulatory and 2 may be bedridden. There are currently 4 residents in care. LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean and at a comfortable temperature with all doors and exits free from obstruction. Fire extinguishers found throughout the facility were charged and inspected within the last 12 months. Smoke detectors and carbon monoxide detectors in resident bedrooms and throughout the facility were tested and found to be operational. Exits of the facility and front entrance have appropriate auditory alarm systems and found to be functioning. Water temperature at faucets accessible to residents was measured and found to be above regulation, between 105 & 120 degrees F. There was an ample supply of fresh linens, continence care and hygiene products available. A tour of the kitchen and food supply was inspected and found to be clean and orderly. Food items were stored properly. Residents are provided various nutritious meals with alternate options and snacks readily available upon request. There was a sufficient amount of food for the number of residents in care. Continued on LIC 809-C... Cleaning supplies, laundry products and other toxins were properly secured in designated storage closets. Medications are centrally stored and secure. A spot medication review was conducted and Centrally Stored Medication Records were found to be in order. At approximately 10:45AM, LPA reviewed 4 of 4 resident files. LPA observed there were 2 residents receiving hospice services. Hospice care plans were not present in the file. 2 of 4 files did not contain resident appraisals. 1 of 4 files did not contain a pre- admission appraisal. Application received by LPA does not contain information regarding whether a hospice waiver was requested or granted. At approximately 11:15AM, Applicant Safir Rezzoug arrived at the facility. Applicant told LPA they did submit a Hospice Waiver request. The Emergency Disaster Plan was reviewed and shows appropriate evacuation sites. Applicant will send verification of liability insurance to CCL once Licensed. Component III orientation was conducted with the Applicant. The pre-licensing evaluation has been completed. LPA requested the following item be submitted before the application will be submitted for file review: - 7 day hot water temperature log showing TWICE DAILY temperature readings for kitchen and resident common bathroom faucets. Upon receipt of the above requested information, LPA will submit application for a final review and approval from the Licensing Program Manager. This report was reviewed with applicant and a copy was provided.the state’s words, verbatim · CDSS document, Sep 23, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census: 2 Method: Telephone call with CAB COMP II Participants: Rezzoug, Safir & Uy, Nancy On 8/28/24, the applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Aug 28, 2024