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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286801534
Report Date: 01/07/2025
Date Signed: 01/07/2025 01:46:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/30/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20241230152601
FACILITY NAME:WINE COUNTRY SENIOR'S VILLAFACILITY NUMBER:
286801534
ADMINISTRATOR:DAVID CERVANTES VIBATFACILITY TYPE:
740
ADDRESS:3552 JEFFERSON ST.TELEPHONE:
(707) 226-3055
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: DATE:
01/07/2025
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Administrator Assistant, Claribel KemperTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility using postural support as a restraint
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegation. LPA met with Claribel Kemper, assistant to the Administrator. Administrator David Vibeat not available to come to the facility but was available by phone and gave Admin assistant permission to sign report.

Complaint alleges facility using postural support as a restraint.

Upon arrival, LPA observed resident (R1) in wheelchair with gait belt being used as restraint. LPA obtained photographic evidence of restraint. Gait belt was fastened, threaded, and tied with belt release placed behind resident in back of the wheelchair, inaccessible to resident to release.


Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20241230152601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINE COUNTRY SENIOR'S VILLA
FACILITY NUMBER: 286801534
VISIT DATE: 01/07/2025
NARRATIVE
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Continued from 9099...

LPA discussed with staff, Admin assistant, and Admin that postural supports cannot be used as a restraint as that is a violation of both personal rights regulation and postural supports regulation. Staff explained they use the restraint because R1 is a fall risk, they try to get up out of the wheelchair constantly. LPA advised engaging the residents with activities suited for their respective cognitive functioning, like sensory blankets for those that can no longer read or fidget tools can also be helpful; they can help mitigate wandering, agitation, and boredom. Staff agree that they will implement these types of activities now that a restraint will no longer be used. So, based on LPA’s observation and staff interview, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

LPA and Admin assistant discussed facility purchasing/providing activities such as sensory blankets, fidget poppers, spinners, and/or tactile devices appropriate for the levels of cognitive functioning of the facility's residents. Admin assistant agrees to purchase/provide the aforementioned items. Admin assistant agrees to send pictures of items purchased/provided to CCL by no later than 1/14/25.

Additionally, LPA observed resident (R2) to have full bed rails present on bed. Per Admin assistant, R2 is not on hospice. LPA discussed with Admin assistant that bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails, per regulation 87608(a)(5)(B). Admin assistant will request full bed rail exception from CCL within 10 business days of this report.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator assistant. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator assistant and a copy of this report was given

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20241230152601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WINE COUNTRY SENIOR'S VILLA
FACILITY NUMBER: 286801534
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered
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Facility to register for and particiapte/attend the ombudsman program for personal rights. Admin to contact the ombusdman to get the date of the next soonest program training and provide the date to CCL by the plan of correction due date. Once attendance/ particiaption is completed
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by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: LPA observation of postural support used as a restraint, which poses an immediate health, safety or personal rights risk to persons in care.
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Admin to submit proof of completion to CCL.
Type A
01/08/2025
Section Cited
CCR
87608(a)(1)
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87608 Postural Supports (a)...Postural supports may be used under the following conditions. (1) ....used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to,
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Admin to submit LIC9098 self-certifying all facility staff will immediately cease using postural supports as a restraint by plan of correction due date.
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preventing a resident from falling out of bed, a chair, etc. This requirement not met by licensee as evidenced by LPA observation of postural support used as a restraint, which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3