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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 09/23/2021
Date Signed: 09/23/2021 05:23:35 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
07/12/2021 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210712124814
FACILITY NAME:VINEYARD AT FOUNTAINGROVE, THEFACILITY NUMBER:
496803698
ADMINISTRATOR:MOONEY, SHAWNFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: DATE:
09/23/2021
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Shawn Mooney-AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff do not safeguard resident's personal belongings
Facility entrance automatic door openers were not working properly
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dina Alviso conducted a complaint inspection, and met with Administrator Shawn Mooney.
LPA has observed the facility's entrance automatic door opener not working properly today, 9/23/21, and on 7/16/21 LPA observed the automatic door openers to not work at all. The facility Administrator had stated to the LPA that there were issues with the door working correctly and the facility was waiting on repairs. LPA was not provided documentation that was official from a service repair company showing proof of addressing the non-working automatic door and/or proof of any part(s) having been ordered for a repair. LPA was provided an email dated 7/16/21, 12:27pm, stating "Tech was out 5/18/2021 to diagnose the door issues, an invoice has not been made yet. Thanks."; This email was sent to the facility maintenance staff the day the LPA was at the facility, 7/16, asking for any records on the automatic door mechanism issues/work orders/invoices. LPA discussed with the Administrator the problems with the automatic door not working, and the Administrator stated that this would be repaired soon. LPAs observed today that the automatic doo's foot opener was not operating as they should, and the Administrator had the maintenance staff repair it today, 9/23/21.
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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-20210712124814
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: 09/23/2021
NARRATIVE
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LPA, on 7/16/21, also discussed with the Administrator, and the Administrator Assistant Annette, personal belongings of residents in care, and the facility's safeguarding procedures. The Administrator stated that they do have residents that may grab items here and there and items are returned as best as staff can back to their resident owners. Administrator stated that clothes even from the laundry items are always being worked on getting items back to resident owners, and the items not marked with identification are the hardest to get done. There are new facility procedures going in place to help address this issue. Assistant Administrator also stated that the facility has had issues with resident's personal belongings get lost and/or more like misplaced for awhile. Administrators Assistant stated that they have been working on what can be done to better safeguard resident items/belongings; Administrator stated the facility has instituted some new procedures into place since last inspection. LPA has received the documentation submitted by the Administrator on the safeguarding of personal belongings.

Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegations of, Staff do not safeguard resident's personal belongings
Facility entrance automatic door openers were not working properly are substantiated.

Due to the substantiation of the allegations, citations will be cited today-see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Deficiencies cited.
Exit interview conducted.
Appeal Rights Given.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20210712124814
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2021
Section Cited
CCR
87468.1(a)(12)
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Personal Rights of Residents In All Facilities-(a)(12)Residents in all residential care facilities for the elderly shall have all of the following personal rights: 12)To wear their own clothes; to keep and use their own personal possessions, including their toilet articles. This requirement was not met as evidenced by LPA's review of records and interviews with staff, and outside parties.
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CORRECTED- ADMINISTRATOR SHAWN MOONEY SUBMITTED THE PLAN OF CORRECTION (POC), SAFEGUARDING RESIDENT PERSONAL BELONGINGS, AND SUBMITTED PLAN TO TRAIN ALL STAFF AS NEEDED ON THE NEW PROCEDURES.
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 The Administrator stated that they do have residents that may grab items here and there and items are returned as best as staff can back to their resident owners. Administrator stated that clothes even from the laundry items are always being worked on getting items back to resident owners, and the items not marked with identification are the hardest to get done. Administrator Assistant (AA) stated that the facility does have an issue of resident personal belongings getting lost and/or misplaced; AA stated they are working on it and instituting new procedures. These are now in place, and the LPA has received documentation of this. LPA discussed the personal belongings of residents and facility procedures. This is a personal rights viiolation of residents in care.
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THIS WAS A POC ON A DEFICIENCY CITED ON 7/23/21, REGARDING RESIDENT PERSONAL BELONGINGS. TODAY THE ADMINISTRATOR STATED THAT THERE IS IMPROVEMENT SEEN IN RESIDENT PERSONAL BELONGINGS BEING SAFEGUARDED, WE CONTINUE TO WORK ON THIS AND MARK CLOTHING ANDITEMSAS NEEDED.
Type B
09/30/2021
Section Cited
CCR
87303(a)
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Maintenance and Operation- 87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by LPA's observation
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Licensee to ensure that there is a plan in place to have facility building/physical plant items within the building able to be repaired and/or replaced as needed, ensuring the facility is able to address these needs as soon as possible, ensuring compliance with regulation 87303(a). Please submit all documentation on the automatic door repairs and parts that have been ordered to repair this since 7/16/21. POC due no later than 9/30/21.
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LPA has observed the facility's entrance automatic door opener not working properly today, 9/23/21, and on 7/16/21 LPA observed the automatic door openers to not work at all. The facility Administrator had stated to the LPA that there were issues with the door working correctly and the facility was waiting on repairs-it has since 7/16 been repaired. LPA was not provided documentation that was official from a service repair company showing proof of addressing the non-working automatic door and/or proof of any part(s) having been ordered for a repair. LPA was provided an email dated 7/16/21, 12:27pm, stating "Tech was out 5/18/2021 to diagnose the door issues, an invoice has not been made yet. Thanks."; This email was sent to the facility maintenance staff the day the LPA was on-site, 7/16/21. LPA observed today, 9/23, that the automatic door's foot opener was not operating as it should, Administrator had the maintenance staff check it and repair it today, 9/23/21. This can be a potential risk to residents personal rights.
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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.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC9099 (FAS) - (06/04)
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