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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 06/20/2023
Date Signed: 06/20/2023 02:40:33 PM


Document Has Been Signed on 06/20/2023 02:40 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:ERIC PERRYFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 45DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Eric Perry, AdministratorTIME COMPLETED:
02:45 PM
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License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Required - 1 Year inspection of the facility. LPA was welcomed by Office Manager Ramona Sandoval. LPA met with Administrator, Eric Perry. There is a total of 45 residents at this full memory care facility. There are 9 residents currently on Hospice.

LPA toured the facility on 6/20/2023 at 11:25 AM with Administrator Eric Perry. LPA observed all exits were unobstructed. Facility fire extinguishers, twelve of them (12 of 12), were last serviced on 8/9/2022. Fire department last inspected 7/2022-no violations noted on inspection date. Smoke alarms are hard wired with combination carbon monoxide detectors. Resident bathrooms have grab bars as required and non-slip flooring in showers. The food supply was sufficient during today's inspection. Hot water temperature measured between 112.2 degrees F and 114.9 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 8 of 8 resident’s bathrooms while touring facility. Resident medications are kept locked and secured in a designated medication room to ensure they are kept inaccessible to residents in care, along with Medication Technicians using two medication carts to disperse medications, that were locked when checked at 1:10pm on 6/20/2023.

LPA initiated a file review of five resident files and six personnel files but were unable to complete. LPA was also unable to review medication and will return at a later date to complete annual inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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