496803698-10-14-2020-21-AS-CMAZ-BUE4LZ-20201014191243

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 10/14/2020
Date Signed: 10/14/2020 12:44:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/28/2020 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200528145026

FACILITY NAME:	VINEYARD AT FOUNTAINGROVE, THE		FACILITY NUMBER:	496803698
ADMINISTRATOR:	EDWARDS, SUSAN		FACILITY TYPE:	740
ADDRESS:	200 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 544-4909
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	64	CENSUS:	DATE:	10/14/2020
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Susan Edwards-Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Residents incontinent needs are not being met in a timely manner.
Residents medications are not being provided as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a televisit inspection, on 10/14/20 at approximately 12:00PM to deliver findings. LPA conducted the televisit with Susan Edwards-Administrator. The inspection is being conducted by tele-inspection due to COVID-19. The reader is advised that the LPA did not physically make a site visit.

The LPA reviewed resident records, including care plans, and medication records. The LPA conducted interviews with staff. The LPA obtained facility's policy and procedures regarding Medication Management and Incontinent Care. The investigation revealed that records were complete as required. Training is being provided to staff that assist residents in taking prescribed medication(s), and to staff that provide care and supervision to residents. There were no names of residents provided with the allegations.
Continued on LIC9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20200528145026

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VINEYARD AT FOUNTAINGROVE, THE	FACILITY NUMBER: 496803698
	VISIT DATE: 10/14/2020

NARRATIVE

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Based on LPAs observations, record reviews, interviews with staff, and review of information obtained from other party(s), there is insufficient information to prove or disprove the allegations of Residents incontinent needs are not being met in a timely manner, and Residents medications are not being provided as prescribed.
Although the allegations may have happened or are valid, there is not a preponderance of
evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s)
are Unsubstantiated.
No citations issued this visit.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020

LIC9099 (FAS) - (06/04)

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