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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 01/30/2025
Date Signed: 01/30/2025 03:05:38 PM

Substantiated


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
11/18/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241118135715
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: 25DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Denise Downey (Executive Director)TIME COMPLETED:
03:05 PM
ALLEGATION(S):
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-Staff are not ensuring that facility kitchen is clean, safe and sanitized.
-Staff do not answer resident's calls for assistance.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Cuadra and Deniz arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Denise Downey, Executive Director.

Staff are not ensuring that facility kitchen is clean, safe, and sanitized. According to reporting party about a month ago residents (R1, R2 & R4) and experienced stomach aches and diarrhea along with some other staff members (names unknown) and apparently it was caused by the food. There is a concern raised by the reporting party that the facility kitchen staff places leftovers in the freezer and it gets reheated multiple times over multiple days. Per the reporting party the kitchen area is not sanitized and only water is used to wipe down the counters. Plates are not washed properly as crusty food remains on the plates. LPA conducted 10-day visit on 11/25/24 toured the facility, made observations, and conducted interviews with Administrator/Executive Director. During toured conducted with Administrator at approximately 2pm, LPA/Administrator observed uncovered and unattended food and drinks as follow: two plates of leftovers were in a kitchen rack...
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 21-AS-20241118135715
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/30/2025
NARRATIVE
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Continued from LIC9099...

approximate 15 pieces of chicken breaded breast, seven chunk pieces of ground meat were in a pan ready to be cooked, 16 pieces of dinner rolls, three 18qt of orange, lemonade, and fruit punch juices. Plastic cups, glass cups, utensils appeared to be cleaned, sanitized without any remains of food on them, they were on kitchen sink drying out. Cleaning tool supplies including brushes, scrubs, dish soaps and other detergents were observed in the locked kitchen area. Also, on the board there was a message for direct staff instructing them the following: "if the dishes have ants, please put it in the back sink”. Upon inquire of LPA with staff regarding the sign, it was revealed that they had been experiencing some ant’s infestation. Per Administrator, uncovered food is not intended to be served to residents in care, they apparently offer it to staff and if nobody wants to eat it, then they throw it away. However, lunch hours are 11:30am-12:30pm and LPA/ED toured the kitchen area at approximate 2pm (pictures taken). Based on interviews conducted with staff (S2, S3, S4, S5, S6) confirmed that housekeepers are observed daily or constantly cleaning the facility using cleaning supplies or washcloths with soap from the kitchen that appears to be adequate for cleaning. Regarding leftovers foods are either given to staff or put together for residents to eat later or the next day and residents get sick often. There is one chef (S9) that the food that they prepare makes residents constantly to get sick. Based on records review provided by the facility to LPA, there is a quality assurance audit report for dietary, kitchen sanitation, daily cleaning sanitation log, housekeeping, and laundry protocol. Based on an outside vendor report dated 11/28/24, they have conducted a service visit, inspected/treated selected areas, pest activity revealed no findings noted during service, but suggesting addressing sanitation issues found in the interior of kitchen area regarding maintenance bucket with used standing water noted next to the kitchen sink area and excess water noted by the floor around the kitchen dish washing area. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given.

Regarding allegation of staff do not answer resident's calls for assistance. Per Reporting Party, Resident (R1) who is bed bound, calls consistently the night shift staff for assistance using their cell phone, but staff do not answer the phone. Continued on LIC9099C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 21-AS-20241118135715
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/30/2025
NARRATIVE
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Continued from LIC9099C...

Based on interviews conducted with resident (R3) who is bedridden, they have revealed that due to the lack of staffing at night shift, there had been times when they have waited about two hours for staff to come and assist them after they have called them using their phone, this incident has occurred at least five to six times during the month of November 2024. According to interviews conducted by LPA with staff including management (S2, S4, S5, S6, S7 & S8) it was confirmed that the call response system has not been working for a while (unknown dates) and residents depending on their level of care could be verbal or non-verbal will react differently by getting up, staff gets the clue when residents need something because they appear confused, concerned or like something is bothering them, along with the two hour checks performed by staff and they have suggested that management needs improvement due to inconsistency or turnover of management. Although, staff do not recall residents using their cell phones to call for assistance. Based on records review of the facility personnel report (LIC500) there are three staff working the night shift and one medication technician to assist 32 residents where there is a total of four residents who needs assistance with incontinence care, and they are identified on their care plans as two-people assist needed. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. Failure to correct the deficiencies may result in civil penalties. The Department will review information obtained to determine if further actions are needed. *Repeated citation in the amount of $250 within the last 12 months.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20241118135715
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2025
Section Cited
CCR
87555(b)(9)
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation, and service. This requirement was not met as evidenced by:
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Licensee to ensure that all staff handle, and stores food as required by regulations; Licensee to ensure that food is handled in a safe manner to ensure food is safe for residents to consume. Submit plan on how the facility will ensure all food handling is in compliance with regulation by POC due date.
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Based on LPA and Administrator observation & interviews the licensee did not comply with the section cited above by not handling food in a safe manner by serving leftover foods to residents and maintaining food uncovered, which poses/posed a potential health, safety, or personal rights risk to persons in care.
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Type A
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Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by licensee as evidenced by:
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The facility agrees to submit proof of call system repairs along with written plan of how staff will respond to resident’s calls for assistance. If additional staff is needed, the facility will hire additional staffing, and will provide proof of updated staff schedule to CCL by POC due date. *Repeated citation in the amount of $250 within the last 12 months.
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Based on records review, observation, and interviews with staff, facility did not ensure staff is sufficient in number to meet residence needs by having call system not working and night shift staff taking up to two hours to respond to resident’s calls for assistance at least 6 times during the month of November 2024, which poses/posed an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
11/18/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241118135715

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: 25DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Denise Downey (Executive Director)TIME COMPLETED:
03:05 PM
ALLEGATION(S):
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-Facility failed to meet residents care needs.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Cuadra and Deniz arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Denise Downey (Executive Director).

The Department received an allegation of facility failed to meet residents care needs. Per Reporting party residents (R1, R2 & R3) had not been changed during the night. Residents’ briefs would be soaked with urine to the point that even the bed sheets were soaked and wearing same clothes for couple days. Resident (R4) would have dried feces on their comforter. When it was brought up to the attention of the manager (S1), they were told that if residents refuse a change of clothing, residents cannot be forced. According to reporting party, this issue is due to staff do not want to change residents’ clothing. Based on records review of resident’s care plans and charting notes for the timeframe between October 1, 2024 - October 31, 2024, there was an incident of resident’s needs not been met on 10/30/24 at 12:54am, one med-technician found resident (R5) covered in dried feces, but the remaining of the notes did not reveal any indication that care needs have not been met by facility staff as stated in their incontinence care plan.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20241118135715
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/30/2025
NARRATIVE
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Continued from LIC9099A...

Based on interviews conducted with facility staff (S2, S3, S5, S6, S10 & S11) staff checks on residents who need incontinence care assistance every two hours in average of three times per night from 10pm-6am, they stated that they were used to have some challenges with night shift who are no longer working at the facility by them not showing up for work on time. LPA have attempted to obtain statements from residents, but they were not able to provide any supporting information to substantiate this allegation. A finding that the complaint allegation occurs of facility failed to meet residents care needs is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6