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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 12/29/2022
Date Signed: 12/29/2022 02:46:57 PM


Document Has Been Signed on 12/29/2022 02:46 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:DARIEN GOSTASFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 40DATE:
12/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Darien Gostas, AdministratorTIME COMPLETED:
12:52 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 a self reported incident report and SOC 341 submitted to Community Care Licensing (CCL).

CCL received an SOC 341 form on 12/16/2022 reporting on 12/16/2022 while staff was escorting resident R1 around facility R1 hit R2 in the shoulder. Staff witnessed incident and intervened, redirecting R1 Facility has increased supervision and doctor has updated medications to ensure residents safety. Facility has conducted care conference with responsible party and doctor. Facility met mandatory reporting requirement. Administrator has informed there has not been any new incidents with R1.

CCL received a self reported incident report reporting on 12/15/2022 resident R3 who had limited cognition, had an un-witnessed fall, hitting head and was sent to ER. R3 was subsequently put on hospice.

No deficiencies cited during today's inspection.








SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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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