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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 08/31/2023
Date Signed: 08/31/2023 02:39:23 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
06/23/2023 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20230623131207
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: 41DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Christina Cruz, Interim AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility did not provide resident with a safe, healthful, and comfortable accommodations
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. During the course of this investigation LPA conducted interviews, made observations, and obtained documents regarding the allegation. LPA met with Christina Cruz, Interim Executive Director.

Facility did not provide resident with a safe, healthful, and comfortable accommodations -Complainant alleges facility had previous knowledge about certain residents violent tendencies and did not address and protect other residents. Community Care Licensing (CCL) received an incident report on 6/10/2023 of Resident (R2) assaulting another resident on 6/9/2023. On 6/22/2023 CCL received another incident report occurring on 6/21/2023 where resident R2 entered R1’s bedroom resulting in a physical altercation, causing bruising to R1’s right arm (photos provided).

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 5
Control Number 21-AS-20230623131207
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: 08/31/2023
NARRATIVE
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Documents obtained by LPA show R2’s Service Plan was never updated, last update was 4/25/2023 that indicated R2 has a record of frequently becoming aggressive, indicating facility had prior knowledge of R2’s violent tendencies and the facility did not update R2’s care plan after either aggressive incident. A lock was requested on resident (R1)’s room and bathroom by R1 and responsible party prior to 6/21/2023 incident. While at facility on 6/27/2023 LPA observed Administrator discussion with R1 stating Administrator was aware of request, however failed to install requested safety measures on R1’s apartment door or joint bathroom. Based on LPAs observations of facility on three different visits (6/27/2023, 7/13/2023 & 8/8/2023), documents reviewed, and multiple interviews conducted with Administrator Eric Perry, Interim Administrator Christina Cruz, staff, and residents. LPA conducted interview with staff confirming the allegation of 6/21/2023, after multiple altercations a 1 on 1 was implemented. Allegation, facility did not provide resident with a safe, healthful, and comfortable accommodations is found to be Substantiated.
A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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 and appeal of right provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20230623131207
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: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
HSC
1569.269(a)(5)(6)
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HSC 1569.269 (a)(5)(6) Enumerated rights...(a) Residents... shall have...rights: (5) To be accorded safe, healthful, & comfortable accommodations...(6) To care, supervision, & services that meet their individual needs & are delivered by staff that are sufficient in numbers, qualifications & competency to meet their needs. This requirement has not been met by:
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Interim Administrator to submit a statement they understand HSC 1569.269(a)(5)(6) & will be in future compliance. Additionally, submit a written plan of how they will ensure residents are safe/ healthful accommodations and not being disrupting to other residents in care. By POC due date of 9/1/2023
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Based on records review, observations and interviews with Administrator, facility did not ensure the health and safety of clients in care by not having proper protocols in place or requested locks, with prior knowledge of R2’s aggressive behavior and repeat assaults.
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Facility has put locks on R1's apt and bathroom doors & Interim Admin has provided personal cell to R1 & R1's POA.
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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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/23/2023 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20230623131207

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: 41DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Christina Cruz, Interim AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not respond to requests for communication about resident in care in a timely manner
Staff did not ensure that resident's personal belongings are safeguarded while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. During the course of this investigation LPA conducted interviews, made observations, and obtained documents regarding the allegation. LPA met with Christina Cruz, Interim Executive Director.

Staff did not respond to requests for communication about resident in care in a timely manner- Complainant alleges facility did not respond to resident’s responsible parties’ phone calls or emails after an incident with R1 occurred, in a timely manner. An incident happened on 6/21/2023 residents responsible parties were notified at (10pm Pacific Standard Time) 1am Central Standard Time that an altercation happened and reporting party alleges it took four hours to receive response. CCL received an incident report on 6/22/2023 of incident on 6/21/2023 at approximately 10 pm with R1 .

Continue on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20230623131207
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: 08/31/2023
NARRATIVE
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The incident occurred at approximately 10pm and per interview with Interim Administrator & staff on 8/31/2023 facility staff called Law Enforcement & R1’s responsible party at 10pm pacific standard time, to inform of incident and same staff was on duty until 11:30pm and had not received a return call to facility message left. Investigation revealed the facility notified resident’s responsible party within 24 hours. Based on reporting parties’ statement and interviews, the facility did notify resident’s responsible party within the time frame required by regulation. This agency has investigated the complaint alleging staff did not respond to requests for communication about resident in care in a timely manner may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Staff did not ensure that resident's personal belongings are safeguarded while in care – Complainant alleges of multiple items residents have removed from R1’s room. Records reviewed for R1 do not show a list of personal belongings. Interviews with R1 and reporting party are not specific on time, dates, and items allegedly removed. There is contradictory information and lack of corroborating evidence, based on interviews with staff, R1, and reporting party, therefore LPA is unable to prove or disprove allegation. Although the allegation of staff did not ensure that resident’s personal belongings are safeguarded while in care, may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5