496803698-1-26-2022-21-AS-BMOS-CBFQDB-20220208110429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 01/20/2022
Date Signed: 01/26/2022 12:36:50 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 Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20210712124814

FACILITY NAME:	VINEYARD AT FOUNTAINGROVE, THE		FACILITY NUMBER:	496803698
ADMINISTRATOR:	MOONEY, SHAWN		FACILITY TYPE:	740
ADDRESS:	200 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 544-4909
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	64	CENSUS: 41	DATE:	01/20/2022
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Annet Nakiyuka, Executive Director & Michelle Larrew, Health Services Director.		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Staff do not respond to resident call bells in a timely manner

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

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 5

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: 01/20/2022

NARRATIVE

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On 6/25/21 at 7:39 am (30.08 min), 6/25/21 10:38 PM (30.12 min), 6/25/2021 11:09 PM (30.15 min), 6/25/21 11:39 pm 30.21 min) 6/26/21 12:10 am (30.03 min) 6/26/21 12:40 AM (30.11 min), 6/26/21 1:10 AM (30.09 min), 6/26/21 1:41 AM (30.07), 6/26/201 3:36 AM (30.09 min), 6/26/21 4:07 AM (30.09 min), 6/26/21 4:37 AM (30.06 min), 6/26/21 10:15 PM (30.09 min), 6/27/21 5:22 AM (30.10 min), 6/27/21 5:53 AM (30.08 min), 6/27/21 6:23 AM (30.08 min), 6/27/21 10:04 PM (30.10 min), 6/28/21 3:01 AM (30.11 min), 6/28/21 4:23 AM (30.18 min), 6/28/21 4:53 AM (30.14 min), 6/28/21 5:24 AM ( 30.15 min), 6/28/21 5:54 AM (30.07 min), 6/29/21 3:28 PM (30.10 min), 6/30/21 8:29 PM (30.10 min), 6/30/21 11:26 PM (27.27 min), 6/30/21 11:58 PM (30.08 min), 7/1/21 2:21 PM (30.16 min), 7/4/21 6:16 PM (30.08 min), 7/6/21 3:43 AM (30.09 min), 7/6/21 4:14 AM (30.11 min), 7/09/21 4:55 AM (30.12 min), 7/9/21 5:25 AM (30.24 min), 7/9/21 10:01 PM (30.15 min), 7/12/21 4:08 PM (30.11 min), 7/12/21 4:45 PM (30.16 min), 7/12/21 5:15 PM (30.22 min), 7/12/21 5:46 PM (30.34 min), 7/12/21 6:17 PM (30.36 min).

Based on LPAs observations and interviews which were conducted and record reviews, 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 of California Regulations.

Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5

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 Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20210712124814

FACILITY NAME:	VINEYARD AT FOUNTAINGROVE, THE		FACILITY NUMBER:	496803698
ADMINISTRATOR:	MOONEY, SHAWN		FACILITY TYPE:	740
ADDRESS:	200 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 544-4909
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	64	CENSUS:	DATE:	01/20/2022
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Annet Nakiyuka, Executive Director & Michelle Larrew, Health Services Director.		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Lack of supervision resulted in resident sustaining an injury
Facility has insufficient staffing
Staff are failing to answer the facility main telephone line
Facility is not providing managed incontinence care to the resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Annet Nakiyuka, Executive Director and Michelle Larrew, Health Services Director.

Lack of supervision resulted in resident sustaining an injury – Record review and interviews conducted revealed R1 was at risk for falls upon admittance. Investigation revealed three falls happened when R1 was getting out of bed to use the restroom. LPA conducted interview with outside party that was providing care for approximately one month in the facility and no information of concern was identified. LPA reviewed staff schedule which appears to have sufficient staff for resident census during this time. Interviews conducted with staff revealed information that was consistent relating to 2-hour room checks. Although resident had three falls LPA was unable to obtain information that these falls occurred due to lack of supervision.

Continued on 9099-C
Facility has insufficient staffing – LPA conducted interviews with outside party and 3 staff, reviewed records, and made observations during the investigation on 9/23/2021 & 11/30/2021. Complainant alleges facility suggested a 1:1 for additional 12 hours at night. Based on LPAs investigation the 1:1 was not due to insufficient staff but due to resident being a fall risk. Record review of staff schedule revealed facility has three staff on night duty which appears to be sufficient for residents in care. Investigation revealed call bell response times were not timely and allegation in support was substantiated and citation issued. LPA was unable to obtain additional information to support facility has insufficient staff. The allegation is unsubstantiated.
Staff are failing to answer the facility main telephone – LPA conducted interviews and made observations. On 7/16/2021, 9/23/2021, 11/30/2021, 12/3/2021, 12/6/2021, 12/27/2021, 12/28/2021, 1/5/2022,1/7/2022/1/10/2022, & 1/11/2022 facility answered main telephone line when CCL/LPAs called. LPA was unable to obtain information to support this allegation. The allegation is UNSUBSTANTIATED.
Facility is not providing managed incontinence care to the resident –LPAs interviews with (3) staff, outside party, and record review concluded in consistent information that resident checks are conducting every 2 hours. LPA conducted an interview with outside party who was going into provide care to R1 weekly for approximately one month. Interview revealed no information to support R1s incontinence needs were not being met. LPA was informed during this interview that for a period R1 had a catheter that hospice was providing oversight. LPA was not able to obtain information to support this allegation. This allegation is unsubstantiated.
Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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: 01/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/31/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to ensure all required facility staff are trained on the emergency call bell alarm system and are following facility's policy/procedures/staffing and ensuring a timely response in answering resident's emergency alarms to ensure that resident's needs are being met.
	8 9 10 11 12 13 14	Based on record review of call bell system & interviews, facility failed to ensure staff are responding to emergency call bell alarms in a timely manner.	8 9 10 11 12 13 14	Licensee to submit plan for training to be submitted by POC due date 01/27/2022. Proof of training to be submitted by 02/31/2022.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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: 01/20/2022

NARRATIVE

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Facility has insufficient staffing – LPA conducted interviews with outside party and 3 staff, reviewed records, and made observations during the investigation on 9/23/2021 & 11/30/2021. Complainant alleges facility suggested a 1:1 for additional 12 hours at night. Based on LPAs investigation the 1:1 was not due to insufficient staff but due to resident being a fall risk. Record review of staff schedule revealed facility has three staff on night duty which appears to be sufficient for residents in care. Investigation revealed call bell response times were not timely and allegation in support was substantiated and citation issued. LPA was unable to obtain additional information to support facility has insufficient staff. The allegation is unsubstantiated.

Staff are failing to answer the facility main telephone – LPA conducted interviews and made observations. On 7/16/2021, 9/23/2021, 11/30/2021, 12/3/2021, 12/6/2021, 12/27/2021, 12/28/2021, 1/5/2022,1/7/2022/1/10/2022, & 1/11/2022 facility answered main telephone line when CCL/LPAs called. LPA was unable to obtain information to support this allegation. The allegation is UNSUBSTANTIATED.

Facility is not providing managed incontinence care to the resident –LPAs interviews with (3) staff, outside party, and record review concluded in consistent information that resident checks are conducting every 2 hours. LPA conducted an interview with outside party who was going into provide care to R1 weekly for approximately one month. Interview revealed no information to support R1s incontinence needs were not being met. LPA was informed during this interview that for a period R1 had a catheter that hospice was providing oversight. LPA was not able to obtain information to support this allegation. This allegation is unsubstantiated.

Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5