496803698-3-2-2021-21-AS-KMOA-BZFLHU-20210325084653

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 03/02/2021
Date Signed: 03/02/2021 08:58:04 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
07/29/2020 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200729094345

FACILITY NAME:	VINEYARD AT FOUNTAINGROVE, THE		FACILITY NUMBER:	496803698
ADMINISTRATOR:	EDWARDS, SUSAN		FACILITY TYPE:	740
ADDRESS:	200 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 544-4909
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	64	CENSUS:	DATE:	03/02/2021
		UNANNOUNCED	TIME BEGAN:	05:20 PM
MET WITH:	Tyler Mason-Administrator		TIME COMPLETED:	06:35 PM

ALLEGATION(S):

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Facility not providing the level of care resident requires.
Due to neglect, resident sustained pressure injuries
Staff did not notify the authorized representative of a change in condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a televisit inspection, on 3/2/2021 at approximately 5:20PM, and met with Executive Director, Tyler Mason, to deliver findings.The inspection is being conducted by tele-inspection due to COVID-19. The reader is advised that the LPA did not physically make a site visit.
The LPA reviewed information provided by the reporting party. The LPA reviewed resident records (R1), including care plans, medical records, incidents, in-home health records, and medication records. The LPA conducted interviews with staff. The investigation revealed that R1 has been their own responsible party, and has a family member involved as wanted and/or needed. R1 is diagnosed with Parkinson's, and also has history of Asthma. R1 aspirated on food while eating, and was diagnosed with trouble swallowing, Due to the current trouble swallowing for R1, the Physician prescribed a special food diet that was appropriate while resident received assistance trying to improve their swallowing; R1 had an occupational therapist and a speech therapist come into the facility to work with them. R1 also would have their regular daily facility care plan services being provided. R1 developed pneumonia, and was being treated for this. R1 Per review of Dr's orders, a Doctor's Order stated to check R1's oxygen saturation once a day, additional instruction to all Nursing staff, and Medication Technicians, if oxygen satuaration was below 95% to notify Executive Director(ED) and/or Resident Care Coordinator (RCC). The ED and/or RCC would ensure resident was immediately assessed for their current needs, notify the Physician and/or 911 if needed.
continued on LIC9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20200729094345

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: 03/02/2021

NARRATIVE

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Per file review, no Dr's orders and/or medical documentation stated resident needed oxygen use by using oxygen tanks or an oxygen concentrator. Oxygen use could be utilized in a community care facility but this would depend on the resident's capabilities, and/ or facility staffing, nurses on-site to assist the residents needs with oxygen use, ensuring compliance with applicable regulations. Per record review, R1 had a stage II pressure injury observed on the coccyx, 3/15/2020, this injury healed with wound care treatment; R1 had a coccyx stage II pressure injury return approximately around 4/28/20 before returning back to the facility from skilled nursing, the resident had wound care treatment provided while in care. The ED ensured a Physician was notified and wound treatment was provided until stage II pressure injury healed. R1 received wound care treatment three times a week for pressure injury. Staff would check R1 every two hours to help reposition R1 to ensure resident would not have continued direct pressure for long periods of time on the coccyx area. Per staff interviews, staff deny resident has been neglected, and state the residents needs are being met. Per record reviews, there was no medical documentation observed of R1's Physician or Medical personnel who have examined R1 and/or treated R1 stating any resident neglect. Per staff interviews, incidents are reported as needed and required. All incidents are reported to the Executive Director, and Health Management staff; Medication Technicians, Executive Director, and Health Management staff , the RCC, are the ones who will document the incident report, and notify the responsible parties as required and needed. S1 stated that all responsible parties of residents are notified as required of incidents and/or changes in condition that are required to be reported to responsible parties of a resident. S1 stated that the contact number used for contacting R1's responsible party was from contact information provided to the facility when R1 was admitted. It was found out when R1 was in skilled nursing that R1's family member's contact information, including phone contact, was changed by the family member but the facility administration staff was never notified. S1 stated this phone contact and email provided from the beginning was used for notifications and documents sent to the family member. S1 stated a notice was given to the facility for R1 to move out; R1 had been in and out of the hospital due to their health decline, and eventually was admitted into a residential care home for the elderly.

Based on LPAs observations, record reviews, interviews with staff, and conflicting information obtained from other related parties, there is insufficient information to prove or disprove the allegations of Facility not providing the level of care resident requires, Due to neglect, resident sustained pressure injuries, Staff did not notify the authorized representative of a change in condition.
Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated.
No citations issued this visit.
Exit interview completed.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021

LIC9099 (FAS) - (06/04)

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