496803698-11-15-2022-21-AS-SHAN-CL7VJ5-20221115152811

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 11/15/2022
Date Signed: 11/15/2022 03:28:16 PM

Document Has Been Signed on 11/15/2022 03:28 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, THE		FACILITY NUMBER:	496803698
ADMINISTRATOR:	DARIEN GOSTAS		FACILITY TYPE:	740
ADDRESS:	200 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 544-4909
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	64	CENSUS: 41	DATE:	11/15/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Darien Gostas Administrator		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Darien Gostas, Administrator. The purpose of this case management inspection is to follow up on two SOC 341’s and a self reported incident report submitted to Community Care Licensing (CCL).

CCL received two SOC 341’s on 10/31/2022. The first reporting on 10/28/2022 staff (S1) reported to have witnessed resident (R1) strike R2 on the side of face. Staff were able to separate residents, no injuries noted. Community nurse contacted both responsible parties, primary care providers, and Local Law Enforcement, event number 223010255. LPA was informed during follow up that R1 has not had any other incidents and R2 continues to be at baseline.

The second SOC 341 reporting on 10/31/2022 R4 expressed to S2 that R3 hit R4. S2 notified other staff and assessed R4, no injuries or complaints of pain. ED notified CCL, LTCO, and Santa Rosa PD by phone and responsible parties, and physicians. This is R3’s 3^rd aggressive incident in 3 months. Facility has requested 1 on 1 for R3 and will monitor R4 for delayed onset of symptoms. During today’s inspection LPA learned R4 has had no adverse side effects from incident. LPA obtained additional information that on 11/7/22 R3 had a 4^th aggressive incident when R3 hit another resident R6 in the arm. Caregiver witnessed incident and redirected. Nurse assessed R6, no injuries. Facility believes due to R3’s medical condition R3 is having periodic mood swings and outbursts. Care conference to be conducted with R3’s family. LPA requests facility to follow up with CCL regarding outcome of conference.

LPA followed up on a self reported incident report received on 11/7/2022 regarding R5 who on 11/5/2022 S2 noticed R5, who on 11/1/22 had a fall, with a significant change in condition, hallucinating, slurred/garbled speech, sleepiness, decreased appetite, and gloomy attitude. Facility contacted R5’s family and sent to hospital for testing. This is all report states. LPA was informed by Administrator R5 returned to facility that evening as of the next day R5 returned to baseline, eating again, and engaging with other residents and staff.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

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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