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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 03/14/2023
Date Signed: 03/14/2023 03:17:55 PM


Document Has Been Signed on 03/14/2023 03:17 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: 38DATE:
03/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Christina Cruz, Assistant Executive DirectorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Christina Cruz, Assistant Executive Director as Interim Executive Director Edie Cano is unavailable. The purpose of this case management inspection is to follow up on a self reported SOC 341 submitted to Community Care Licensing (CCL).

CCL received an SOC 341 form from facility on 3/1/2023 reporting on 2/26/2023 at approximately 9:00PM staff (S1) had allegedly hit resident (R1) three times, which was reported by S2.

Facility submitted reports cross reported to Santa Rosa Police Department and Ombudsman, responsible party notified. LPA made copies of internal investigation notes, facility files, and resident chart notes.

Interim Administrator was reached by Assistant ED via phone and agrees to inform LPA when full internal investigation is complete and how facility is going to proceed regarding alleged abuse reported. Interim Administrator is conducting all staff meeting this week with training on reporting requirements of a mandated reporter, disciplinary actions of false reporting, and job duty requirements.

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: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
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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