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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 12/31/2024
Date Signed: 12/31/2024 12:09:14 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20241112160143
FACILITY NAME:VINEYARD AT FOUNTAINGROVE, THEFACILITY NUMBER:
496803698
ADMINISTRATOR:ANTONETTE EDWARDSFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 28DATE:
12/31/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Serina BarredaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
Facility staff did not dispense medication accurately resulting in resident's death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. An anonymous Complainant has alleged that Resident R1 was administered morphine prescribed for another resident and that R1 died as a result. Based upon statements and documents reviewed the following determinations are made: R1 was prescribed morphine while on Hospice for pain following a fall on 11/2; R1 died on 11/9/2024; Facility Health and Wellness Director denies that R1 was given morphine prescribed for another resident and states R1 was administered morphine as directed that was prescribed for R1; The Death certificate for R1 gives the cause of death as Alzheimer's Disease with several other contributing factors, none of which result from medication or toxicity; no autopsy was done on R1. Although the allegation may be valid, based upon documents and statements, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
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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