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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 05/03/2022
Date Signed: 05/03/2022 01:28:38 PM


Document Has Been Signed on 05/03/2022 01:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:VINEYARD AT FOUNTAINGROVE, THEFACILITY NUMBER:
496803698
ADMINISTRATOR:NAKIYUKA, ANNETFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 43DATE:
05/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Annet NakiyukaTIME COMPLETED:
01:00 PM
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Licensing Program Analyst Leibert arrived unannounced for the purpose of following up on an incident that occurred at the facility on April 22, 2022. Staff found the remnants of a bullet inside resident's room at the facility when investigating a broken window. Santa Rosa Police were summoned and appeared later the same day. LPA learned that the resident was moved to another room and currently remains there at the request of family. The window has been secured and will be replaced this week. LPA determined that the facility administration has taken appropriate action upon discovering the incident and that reasonable steps were made to protect and secure the building and residents. LPA toured the facility, interviewed the Administrator, and obtained pictures taken at the scene by the Administrator. Pending receipt of the report of the Santa Rosa Police Department, it is determined that no further action is required.

No citations issued today.

Copy of report left at facility.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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