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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 02/22/2021
Date Signed: 02/22/2021 05:27:16 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2020 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200703122508
FACILITY NAME:VINEYARD AT FOUNTAINGROVE, THEFACILITY NUMBER:
496803698
ADMINISTRATOR:EDWARDS, SUSANFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: DATE:
02/22/2021
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Tyler Mason-Executive DirectorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff did not notify residents authorized representative of resident incidents
Staff locked resident in a room
Staff neglected residents care needs
Lack of supervision resulting in resident falling
Resident sustained pressure injuries while in care due to neglect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a televisit inspection, on 2/22/2021 at approximately 4:00PM, and met with Executive Director, Tyler Mason, to deliver findings. The inspection is being conducted by tele-inspection due to COVID-19. The reader is advised that the LPA did not physically make a site visit.
The LPA reviewed information provided by the reporting party(s). The LPA reviewed resident records (R1 & R2), including care plans, medical records, incidents, in-home health records, and medication records. The LPA conducted interviews with staff. The investigation revealed that R1 had a fall incident 3/12/20 while taking a walk outside of the facility with a staff person. The resident was assessed by the staff for injuries; R1 was documented as having bruising on the left side of their face from the fall incident of 3/12/20. R1 was seen by a medical professional on 3/12/20, was diagnosed with having a mechanical fall, having slipped, tripped, or lost their balance, and diagnosed with a sprained wrist, per medical documentation; Medical documentation stated that no fractures or head injuries could be seen on x-rays taken that day, 3/12/20. R1 had a follow-up appointment with the Physician to check the sprained wrist. R1 does not have a history of falls. R1 had a care plan in place, and did not have a one to one staffing need per review of records. R1 was identified as having staff supervision while taking a walk outside. Per staff interviews, staff 2 stated to the LPA that resident R1's responsible party was notified of this incident. Staff stated that responsible party(s) were notified of incidents that occurred that involved R1 and/or R2 as required.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021
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 2
Control Number 21-AS-20200703122508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: VINEYARD AT FOUNTAINGROVE, THE
FACILITY NUMBER: 496803698
VISIT DATE: 02/22/2021
NARRATIVE
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Per record review and interviews, R1 was scheduled to be moved out of the facility on 5/28/20; All residents belongings were being packed to be moved out with the resident; R1 was observed by staff to be very upset and emotional during the day of planned move out by R1's responsible party. R1 was in the office of a staff person, wanting to stay away from their room, stating that they wanted to remain in the facility with R2, and are being forced to move out. Staff 2 stated that R2 was not being moved out by responsible party, and R2 would continue residing at the facility. An ombudsman, who is an advocate for residents, was at the facility, and was a help with the move out situation of R1. The Police did respond as well to ensure the well being of the resident and to check on what was the actual situation involving the resident. Staff stated that they reviewed, and ensured that the legal documentation on POA was still valid and who was named to legally make the decisions for financial, medical, and care needs of R1. Staff 2 denies that the resident was kept locked up in any room at any time but that R1 was upset, and asking to be in staff office area and asking for staff's help. S2 stated that staff tried to calm the resident down, and continued speaking with the resident throughout the situation that day. R1's responsible party came to see and speak with R1, and also received all R1's medication to take to the new facility. R1 did finally agree to the move out, and was transferred out later that day, on 5/28/20. R1 was not taken out forcefully by any party but went willingly in agreement with the move out that was planned by legal responsible party of R1.
Per review of R2 records, including medical records, R2 was diagnosed with difficulty swallowing, and was put on Dr. ordered diets as needed; Resident had a Speech Therapist and Occupational Therapist to provide needed professional care services in addition to resident's plan of care. R2 has an order for protein shakes to be given in between meals due to resident having lost weight; R2 has advanced Parkinson's, which is listed in medical documentation, and documented also in relation to falls of R2, Resident has a history of falls, and a care plan that addresses residents current needs. R2 does not have a one to one staffing need per review of facility records, and care plan. R2's care plan includes incontinence care; Per medical documentation R2 was diagnosed with a hemorrhagic cystitis but no medical documentation provided stated that the diagnosis was due to any neglect of care needs and/or catheter care neglect. Review of records identify that staff notified the Physician of possible UTI of R2, and requested Physician assistance with testing and medication if needed. Per record review, R2 has had two pressure injuries and they were stage II; R2 was receiving appropriate wound care treatment by a medical professional, and wound care treatment was approximately three times a week. Per staff interviews, staff deny resident has been neglected, and state residents needs are being met. Per record reviews, there was no medical documentation stating any neglect of resident by staff and/or staff not providing services needed.

Based on LPAs observations, record reviews, interviews with staff, and conflicting information obtained from other related parties, there is insufficient information to prove or disprove the allegations of Staff did not notify residents authorized representative of resident incidents, Staff locked resident in a room, Staff neglected residents care needs, Lack of supervision resulting in resident falling, Resident sustained pressure injuries while in care due to neglect.
Although the allegation 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 allegation(s) are Unsubstantiated. No citations issued this visit. Exit interview completed.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021
LIC9099 (FAS) - (06/04)
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