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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 07/27/2022
Date Signed: 07/27/2022 01:02:10 PM


Document Has Been Signed on 07/27/2022 01:02 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, THEFACILITY NUMBER:
496803698
ADMINISTRATOR:NAKIYUKA, ANNETFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 39DATE:
07/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Annet Nakiyuka (Administrator)TIME COMPLETED:
01:17 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Administrator Annet Nakiyuka to conduct a case management visit regarding a recently self-incident report (SIR) along with SOC341A which resulted in a suspected verbal abuse. SIR report was submitted to CCL on 7/25/22.

Per incident report, the incident occurred on 7/21/22 at approximately 3:30pm facility staff (S1) heard one on one caregiver (I1) raise their voice angrily and swear at resident (R1) then heard what sounded like a slap to R1. S1 heard the incident from the hallway outside R1's room. S1 notified the medication technician/concierge who notified Administrator who notified staff (S2). S2 spoke with S1 then contacted agency caregiver employer to notify them about the alleged verbal abuse. Also, R1's responsible parties including their Physician and Long Term Ombudsman were notified. R1 was assessed by facility nurse and no apparent injury, bruising or physical signs of abuse was observed.

During today's visit LPA was provided with a copy of written statement from S1 describing the incident. LPA also learned that R1 is currently residing at the memory care unit and no concerns had been raised by their responsible parties. A copy of an internal email record from the facility Health Services Director to Administrator indicates that the police was contacted. The email dated 7/26/22 at 10:09pm indicates that the police officer Mr McCaulous was contacted via phone on 7/22/22, but there was no police report generated, the police officer did not came to the facility, police officer did talk to R1 over the phone for over 5-10 minutes and since there were no injuries noted no further action was done by the police. LPA will follow up and request police report to support the investigation. There was an internal investigation conducted by the facility, but there was no report generated as of today yet, but Administrator agreed to submit a copy to CCL by not later than 8/21/22, but based on interviews conducted by Administrator with staff, the allegation is probably not substantiated. LPA also obtained temporary agency contact information. Administrator will submit SOC341 to CCL for review.

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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