496803698-1-17-2023-21-AS-SHAN-CN6US6-20230117144950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 01/17/2023
Date Signed: 01/17/2023 02:50:01 PM

Document Has Been Signed on 01/17/2023 02:50 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:	01/17/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Assistant Executive Director - Christina Cruz		TIME COMPLETED:	02:50 PM

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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Assistant Executive Director Christina Cruz as Darien Gostas, Administrator was out. The purpose of this case management inspection is to follow up on three self-reported incident reports and two SOC 341’s submitted to Community Care Licensing (CCL).

CCL received a self-report incident report and SOC 341 form on 1/3/2023 reporting on 12/30/2022 resident (R1) was witnessed in R2’s room being requested to leave by R2. It was reported to Administrator that the witness to this incident believes R1 is abusing R2, however there has been no reported incidents of this occurring. Facility has installed a special lock on R2’s door and R1 has a private care giver in place for increased supervision.

Administrator submitted reports cross reported to Santa Rosa Police Department and Ombudsman, responsible party notified. LPA to be sent copies of internal investigation notes, photos and records. LPA conducted interviews and made observations.

LPA followed up on an incident submitted to CCL on 1/9/2023 regarding an incident that occurred on 1/8/2023. Incident states at 3:26 PM Resident (R3) had eloped from community, facility, family, and law enforcement conducted search and located R3 and returned to community. Facility informed R3 went into an empty room and exited through window that sent alarm to in house pagers. LPA is issuing a citation today for R3 eloping from facility without staff knowledge on 1/8/2023. Due to a previous incident of elopement on 12/5/2022 where facility was cited for the same deficiency. LPA is issuing Civil Penalty for a repeat violation within a 12 month period.

Continue on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

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: 01/17/2023

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While at today’s case management LPA received a copy of an incident report and SOC341 that occurred on 1/14/2023 between two residents and were submitted to CCL over the weekend. At approximately 8:40 pm R4 was witnessed by staff (S1) to hit R5 on the nose. Residents were separated and R5 was assessed with no signs of injury. Administrator submitted reports cross reported to Santa Rosa Police Department and Ombudsman, responsible party notified. LPA was informed R4’s one on one caregiver recently changed hours to leave earlier but now will stay until 10 pm.

**Civil Penalty are issued today in the amount of $250 for a repeated violation within a 12 month period.

Appeal of Rights Given.

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

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/17/2023 02:50 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: 01/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/18/2023 Section Cited	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.	1 2 3 4 5 6 7	Facility to ensure all exits have delayed egress and windows have alerting systems. Administrator informs R1 has moved out of facility 1/9/2023. Administrator agrees to submit LIC9098 that the staff understand the regulation.
	8 9 10 11 12 13 14	Based on record review, self-incident report dated 9/9/2023, and interviews conducted with Administrator, R1 eloped without staff knowledge on 9/8/2023. The facility did not comply w/section above to address behaviors such as wondering for R1 which poses an immediate Health, Safety risk to residents in care.	8 9 10 11 12 13 14	*****Civil penalties are issued today in the amount of $250 per repeated violation within 12 months.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

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