496803698-6-9-2022-21-AS-SHAN-CF8UZR-20220609160157

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 06/09/2022
Date Signed: 06/09/2022 04:02:11 PM

Document Has Been Signed on 06/09/2022 04:02 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, THE		FACILITY NUMBER:	496803698
ADMINISTRATOR:	NAKIYUKA, ANNET		FACILITY TYPE:	740
ADDRESS:	200 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 544-4909
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	64	CENSUS:	DATE:	06/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Michelle Larrew, Health Services Director		TIME COMPLETED:	04:01 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by staff Elisabeth. LPA was informed Administrator Annet Nakiyuka was at CALA conference and Health Services Director Michelle Larrew is standing in. Facility has 42 residents with 2 residents bedridden and 7 residents on Hospice. Facility is a full dementia care. LPA arrived at the facility and had temperature checked. LPA answered screening questions of sign-in device. Tour of facility began at approximately 11:45 am with Health Services Director Michelle Larrew and Environmental Services Director Hercules Cuevas. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 8/6/2021 at the time of the visit. Smoke Detectors & Carbon monoxide detectors were checked in February 2022 by Santa Rosa Fire Department and found to be operational. There was a sufficient amount of supply for both perishable and nonperishable foods as required. Food stored in the kitchen refrigerator was properly stored at the time of the visit. The resident bathrooms observed by LPA had required grab bars, and non-slip mat/non-slip flooring for the showers. All resident’s bedrooms have lighting & appropriate furnishings. In 9 out of 11 residents bathroom faucets hot water temperature measured between 120.3 degrees F and 124.3 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees (see LIC 809-D). Medications are kept secured as required in a locked medication room. Toxins and cleaners are kept secured in locked storage areas. Disaster drills are conducted quarterly with the last being a fire drill on 4/4/2022. Infection Control: Facility has submitted a mitigation program plan that has been approved 7/13/2021. Posters have been placed at facility and entrance has electronic sign in and temperature check with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in an empty office room. All staff had masks on during this visit. Staff had all PPE training required on file and have received N-95 fit testing. All staff who are eligible to receive their COVID -19 Booster shot have. Continue on LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, THE	FACILITY NUMBER: 496803698
	VISIT DATE: 06/09/2022

NARRATIVE

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LPA reviewed Licensing Information System (LIS) with designee who stated that is correct and updated at this time. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA viewed Administrator Certificate for Annet Nakiyuka # 6061965740 Exp. 4/11/2024.

LPA was presented with proof of CPR & 1^st Aid certification for staff.

LPA discussed new PIN 22-18-ASC regarding Infection Control Plan due in CCL by 6/31/2022

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. 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.

Appeal of Rights Given

LPA Hansen is requesting Administrator to update and submit the following documents by 6/24/2022 to RPRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/09/2022 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, THE	FACILITY NUMBER: 496803698
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance & Operation. Hot water provided for the use of residents shall be maintained between 105 and 120 degrees F. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee failed to have hot water temperature between 105 & 120 F in 9 of 11 resident's bathrooms which poses an immediate Health, Safety risk for residents in care. LPA toured the facility and observed that 9 of the 11 hot water temperature ranged between 120.3 and 124.3 degrees F.
	POC Due Date: 06/10/2022
	Plan of Correction
1 2 3 4	Administrator to ensure water temperature is maintained within regulation of 105 TO 120 F. As per Environmental Services Director Hercules Cuevas who informed hot water temperature has been adjusted today. Facility to begin monitoring for the next 7 days. Administrator to submit a 7 day log taken from the resident's bathrooms to CCL by 6/16/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC809 (FAS) - (06/04)

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