496803698-10-2-2023-21-AS-BMOS-CWFP5P-20231009110103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 10/02/2023
Date Signed: 10/02/2023 02:16:27 PM

Unsubstantiated

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
07/06/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20230706090520

FACILITY NAME:	VINEYARD AT FOUNTAINGROVE, THE		FACILITY NUMBER:	496803698
ADMINISTRATOR:	ERIC PERRY		FACILITY TYPE:	740
ADDRESS:	200 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 544-4909
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	64	CENSUS: 42	DATE:	10/02/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Joseph Hansen, Executive Director, Christina Cruz, Business Office Director, & Kimiyo Jones, Health Services Director.		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care-
Staff did not seek timely medical attention for resident-
Staff did not administer resident’s insulin in a timely manner-
Facility staff did not meet residents care needs-

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 Joseph Hansen, Executive Director, Christina Cruz, Business Office Director, & Kimiyo Jones, Health Services Director.

Resident sustained unexplained injuries while in care – Complainant alleges resident fell multiple times. Documents obtained during investigation from facility indicate resident had documented falls multiple times, some sustaining injuries and some not, and with 2 times resulting in resident going to the hospital. Resident records show not requiring needing one to one care. Facility submitted required incident reports to the department. Based on review of reports and interviews the department is not able to prove or disprove resident sustained unexplained injuries while in care. Therefore, the allegation is Unsubstantiated.
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

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 3

Control Number 21-AS-20230706090520

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: 10/02/2023

NARRATIVE

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Staff did not seek timely medical attention for resident – Complainant alleges on approximately 06/17/23 R1 had swelling above knees and on 06/22/23 R1’s family observed R1’s pants were wet due to fluid weeping from legs. Facility was aware but did not provide medical attention in a timely manner. Chart notes indicate on 6/10/2023 in am resident (R1) was noted to appear to have edema in ankles. Home health notes on 6/13/23 for R1 needs legs elevated 2-3 X per day for edema swelling & placed on exercise program, instructions posted on wall. New medication orders started on 6/13/2023. LPA obtained facility records stating at approximately 9:45pm on 6/15/2023 R1 begins to walk around facility, was put back to bed and found roaming facility again at approximately 10:30 pm and redirected back to bed again. On 6/17/2023 at approx. 8:30 am S1 indicates in chart notes observed possible increase in right lower leg edema and sent fax to Dr. who conducted video appointment. LPA’s interview with S1 indicated not knowing of increase of edema until 6/17/2023 and when examining S1 palpated the area and R1 didn't say it was painful. R1 started a new medication to help relieve the swelling in the legs after 6/17/23. Investigation revealed Chart notes indicated facility contacted Dr. multiple times (6/10, 6/11, 6/12, 6/14, 6/16, 6/17 etc..) and made attempts to redirect resident per home health. Based on record review and interviews with staff, the department is not able to prove or disprove staff did not seek timely medical attention. Therefore the allegation is Unsubstantiated.

Staff did not administer resident’s insulin in a timely manner- Complainant alleges on 6/17/2023 resident (R1) did not receive scheduled insulin until an hour and 45 minutes later than it was supposed to be administered. Staff (S1) informed LPA a nurse earlier that day had sent in an order to the pharmacy for 10 units and the pharmacy sent back a change of insulin order for R1 incorrectly and changing R1’s Medication Record (MAR) to an old order from past insulin prescription. As S1 didn't have an order from the prescribing physician S1 called the physician to clarify, by then it was 10:30 am and S1 didn't want to administer the full dosage of units and then administered the 11 am shortly after as that much insulin would have dropped R1 significantly too low. To prevent a medical problem the physician directed S1 to administer 5 units and sent the fax for 5 units at 10:30am. And proceed for regular insulin dose at 11:30am. There was an error made but not necessarily on the fault of the facility in this instance. LPA obtained resident records corroborating S1’s events. Based on record review and interviews with staff the Department is not able to prove or disprove staff did not administer resident’s insulin in a timely manner. Therefore, the allegation is Unsubstantiated.

Continue on LIC9099-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20230706090520

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: 10/02/2023

NARRATIVE

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Facility staff did not meet residents care needs- Complainant alleges resident was found without shoes and socks on numerous times and without their walker. Through this investigation interviews were conducted and records reviewed. The review of care plan shows resident had a behavior of leaving shoes and socks in different locations. Staff were aware and would put shoes and socks or non-skid socks on resident, as well locate walker and attempt to get resident to use as resident would leave walker in other resident’s rooms and in hallways. Based on record review and interviews with staff the department is not able to prove or disprove facility staff did not meet residents care needs. Therefore, the allegation is Unsubstantiated.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC9099 (FAS) - (06/04)

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