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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 02:37:27 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
01/02/2025 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20250102133905
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 LLCTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility's fire system is in disrepair
INVESTIGATION FINDINGS:
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While conducting Office meeting at the Santa Rosa Regional Office findings of the investigation were delivered.
Complaint alleges facility’s fire system is not in compliance with fire regulations. Community Care Licensing (CCL) received information that the facility’s fire alarm has not been functioning for approximately a year and facility has neglected to respond to fire department or vendor to get fixed. Documents obtained on 1/17/2025 from Fire Department revealed routine fire inspection conducted on 10/19/2023 indicated Fire alarm panel showed trouble fault, fire inspector requested be corrected by 11/18/2023. Fire Department followed up with an email to facility on 11/6/2023. LPA conducted visit of facility on 1/9/2025 and staff interview revealed the Licensee is working on the issue, but system has not been repaired yet. Documents obtained revealed vendor has provided estimate/proposal that includes replacement of nonfunctioning part as current is also, no longer available, facility has signed proposal. 1/10/2025 interview with executive director indicated they are following fire inspectors’ requirements until system is functioning properly.
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-20250102133905
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

Although, documents obtained from facility on 1/15/2025 reveal staff (S1) is the only employee who has signed off on Fire watch log for all 3 locations (lobby, east side, west side) from 1/8/2025 at 8am through 1/14/2025 at 4:30pm every 30 minutes, PM & NOC shift not provided. On 2/10/2025 Administrator informed system still not fixed and resubmitted Fire Watch Log from 1/8/2025 through 2/5/2025 for all 3 shifts, every 30 minute, although NOC shift for 1/8-9, 1/10-11, 1/11-12, 1/12-13, 1/13-14, & am/pm of 1/18/2025 did not have names or signatures of staff who conducted watch.

Allegation Facility’s fire system is in disrepair 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.

***Immediate Civil Penalty assessed in the amount of $500 due to fire clearance violation.



The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. 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 rights provided.
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-20250102133905
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
87202(a)
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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
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Submit self-certification they will continue to follow fire marshals’ guidance. And notify CCL when system is functioning.
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This requirement is not met as evidenced by:

Based on LPA interviews the fire system has not been functioning properly for approximately 1 year which is an immediate health and safety risk to residents in care.
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**Immediate Civil Penalty assessed in the amount of $500 due to fire clearance violation.
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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)
Page: 3 of 3