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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 01/09/2025
Date Signed: 01/09/2025 11:10:57 AM

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
07/03/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240703123817
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: 26DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Denise Downey (Executive Director) and Business Offica Manager, Serina BarredaTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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-Staff are mishandling the residents medications.
-Staff are not being properly trained.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Marisol Cuadra and Robert Frank conducted an unannounced visit and met with Business Offica Manager, Serina Barreda and Denise Downey, Executive Director. Complainant alleges multiple allegations that are noted above and referenced below in detail.

Staff are mishandling the residents’ medications - Complainant and Co-complainant (added 10/11/2024) allege that facilty fails to administer medication as prescribed by doctor, not limited to missed doses of insulin, glucose readings, late doses and charting medication has been administered but has not. Complainant also informs of medication not being destroyed per regulation. Based on record review CCL has received multiple self-report incidents of medication error. On 6/17/2024 the Med Tech failed to assist with R1s blood glucose check subsequently resulted in R1s missed insulin. This was a self-reported incident submitted to CCL on 6/27/2024. On 5/24/2024 CCL received a self-reported incident that on 5/23/2024 it was revealed that R2 had been out of a prescribed medication for several days.
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
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 5
Control Number 21-AS-20240703123817
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: 01/09/2025
NARRATIVE
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Continued from LIC9099...

Although the Med Techs had documented that the medication was administered. Med Tech was suspended pending investigation. Therefore, the allegation of Staff are mishandling the residents’ medications is Substantiated.

Staff are not being properly trained- Complainant and Co-complainant (added 10/11/2024) allege staff are not receiving training per regulation and initial hire training as well as required First Aid/CRP training. Allegation related to annual and initial training was investigated and delivered unsubstantiated under complaint 21-AS-20240722094535 indicating; LPA obtained a sample of (4) new hire training records and logs. Based on review of training records and interviews conducted facility appears to be in compliance with regulation pertaining to staff training. Based on additional records reviewed on 7/16/2024 specific to first Aid training it was revealed that 4 out of 7 (S1, S2, S3 & S4) staff did not have First Aid training. Therefore, the allegation of Staff are not being properly trained is Substantiated.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Repeated citation within a 12-month period resulted in $250 civil penalty issued. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20240703123817
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: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a)...(4) The licensee shall assist residents with self-administered medications as needed. This requirement has not been met as evidence by:
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Licensee will conduct an all-Med Tech training to review facilities policy pertaining to medication.
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Based on record review CCL has received multiple self-report incidents of medication error which poses an immediate risk to the health and safety of residents in care.
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Type B
01/10/2025
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:
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The Licensee will submit a self certify (LIC9098) review of all staff first aid training and plan to ensure compliance with regulation. Repeated citation within a 12-month period resulted in $250 civil penalty issued.
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Based on additional records reviewed on 7/16/2024 specific to first Aid training it was revealed that 4 out of 7 (S1, S2, S3 & S4) staff did not have First Aid training which poses a potential risk to the health and safety of the residents 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: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 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
07/03/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240703123817

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: 26DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Denise Downey (Executive Director) and Business Offica Manager, Serina BarredaTIME COMPLETED:
11:25 AM
ALLEGATION(S):
1
2
3
4
5
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9
-Staff are not providing adequate care and supervision to the residents.
-Staff are not providing adequate supplies for the residents.
-Staff are withholding food and drinks from the residents.
-Staff are not properly maintaining the residents rooms.
-Staff are not repairing the broken lights in the facility.
-Staff are sharing the residents personal supplies while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Marisol Cuadra and Robert Frank conducted an unannounced visit and met with Business Offica Manager, Serina Barreda and Denise Downey, Executive Director. Complainant alleges multiple allegations that are noted above and referenced below in detail.

Staff are not providing adequate care and supervision to the residents- Complainant and Co-complainant (added 10/11/2024) allege staff are not providing adequate supervision resulting in care needs not being met. During the course of the investigation LPA made observations not limited to 7/9/2024, 7/16/2024 and 8/15/2024 while conducting complaint investigation. LPA obtained staff schedule consisting of AM, PM and NOC shifts which appear to be sufficient to meet the care needs of 33 residents during this time period. Based on observation, record review and interviews LPA was unable to obtain information that staff are not providing adequate care and supervision. Therefore, this allegation is Unsubstantiated.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20240703123817
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: 01/09/2025
NARRATIVE
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Continued from LIC9099A...
Staff are not providing adequate supplies for the residents- LPA made observations in the facility on 7/9/2024, 7/16/2024, 7/30/2024, 8/13/2024, 8/15/2024, 8/21/2024 and 9/10/2024 and observed a sufficient supply on supplies to meet the needs of residents in care. LPA obtained photos of care products in multiple locations in the facility. LPA conducted interviews with staff and was unable to obtain information to support this allegation. This allegation was also investigated under complaint 21-AS-20240722094535 and found to be unsubstantiated.
Staff are withholding food and drinks from the residents- LPA made observations in the facility on 7/30/2024, 8/13/2024, 8/15/2024, 8/21/2024 and 9/10/2024 and perishable and non-perishable foods appeared to be in compliance with regulation. LPA obtained photos of food supply and meals being prepared and offered to residents. LPA conducted interviews with staff and was unable to obtain information to support this allegation. Staff informed that snacks and drinks are available at all times outside of meal hours. Therefore, this allegation is found to be unsubstantiated.
Staff are not properly maintaining the residents’ rooms-During the course of the investigation LPA made observations in the facility on 7/30/2024, 8/13/2024, 8/15/2024, 8/21/2024 and 9/10/2024 and did not observe the noted areas in the facility that are not kept clean and sanitary. LPA conducted interviews, obtained photos and made observation in multiple (5) resident’s rooms. This allegation was also investigated under complaint 21-AS-20240722094535 and found to be unsubstantiated.
Staff are not repairing the broken lights in the facility- LPA made observations in the facility on 7/9/2024, 7/16/2024, 7/30/2024, 8/13/2024, 8/15/2024, 8/21/2024 and 9/10/2024 and observed two lights out. LPA was informed that they have been replacing light bulbs and are waiting on the supplier to send more to continue to replace. Staff attempted to purchase at local hardware store and was unsuccessful; Based on LPAs observation there was adequate lighting and the few bulbs observed out did not pose a threat to the health and safety of residents in care. Facilty is actively replacing broken lights. Therefore, the allegation is found to be unsubstantiated.
Staff are sharing the residents’ personal supplies while in care- LPA made observations in the facility on 7/9/2024, 7/16/2024, 7/30/2024, 8/13/2024, 8/15/2024, 8/21/2024 and 9/10/2024 and observed a sufficient supply and supplies to meet the needs of residents in care. LPA obtained photos of care products in multiple locations in the facility. LPA conducted interviews with staff and was unable to obtain information to support that staff are sharing residents personal care products. This allegation is found to be unsubstantiated.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations above are found to be unsubstantiated.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5