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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 03/21/2025
Date Signed: 03/21/2025 02:33:22 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
12/26/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20241226154520
FACILITY NAME:VINEYARD AT FOUNTAINGROVE, THEFACILITY NUMBER:
496803698
ADMINISTRATOR:SANDHU,RAJVIRFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 22DATE:
03/21/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:CEO of One Life Senior Living, Dan Williams , VP Quality Assurance, Joe Diagle of Frontier Living, and Administrator, Denise Downey, One Life Senior Living LLC TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Licensee does not ensure facility is adequately staffed to meet residents needs
INVESTIGATION FINDINGS:
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While conducting Office meeting at the Santa Rosa Regional Office findings of the investigation were delivered.

Complaint alleges in December 2024 due to lack of staffing at facility, they weren’t equipped to provide residents with assistance or a task to get their minds off things. LPA’s additional interview with reporting party also informed there was not any activities during December except at the end of December when the sales manager was beginning to conduct 2 morning classes. There wasn’t even any music being played in December. Interview with new executive director and Staff (S1) on 1/23/25 informed the facility lost its activities director 11/30/25 and so at some point in December the sales director was conducting 2 activities per day. Facility resident roster for 12/2024 reveals there were 30 residents in care, interviews and documents obtained revealed there were 4 residents that are (2) person assist, and 26 residents (1 person assist), and 3 residents on Hospice.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
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 3
Control Number 21-AS-20241226154520
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: 03/21/2025
NARRATIVE
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Continued from LIC9099

Based on staff schedule and interviews for 12/2024 it was revealed staffing is as follows: one medication technician on shift at all times, and 4 caregivers (2 on each side) for the morning shift & evening shift and, 3 caregivers for the entire facility on the nighttime (NOC) shift. LPAs 1/9/2025 interview with staff (S2) revealed the facility has not had regular activities in months. They just started doing activities again recently and don't have a dedicated person for activities. Resident (R1) interview of 12/31/2025 informed there aren't enough staff, especially at night. I have waited 2 hours for staff to assist me after I call. LPA requested call system log from S1 who failed to provide informing function does not work & does not have access to the report. Based on interviews and record review it appears facility does not have sufficient staffing, therefore the allegation Licensee does not ensure facility is adequately staffed to meet residents needs is Substantiated.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Civil Penalties in the amount of $250. (1/9/25 & 1/30/25) for 3rd repeat of same citation provided within the last 12 months.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit Interview Conducted.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20241226154520
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: 03/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2025
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: Based on records review, observation
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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.
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, 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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*Civil Penalties for 3rd repeated citation in the amount of $250. within the last 12 months.
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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: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
LIC9099 (FAS) - (06/04)
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