496803698-10-2-2023-21-AS-BMOS-CWFNY8-20231009105219

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 10/02/2023
Date Signed: 10/02/2023 02:37:50 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
09/29/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20230929111257

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		TIME COMPLETED:	10:23 AM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and delivered findings regarding the allegation listed above and met with Executive Director Joseph Hansen, Health Services Director Kimiyo Jones, & Business Office Director Christina Cruz.

During investigation LPA reviewed documents, made observations, and conducted interviews.

Personal Rights - Complainant alleges resident's (R1) room was not locked as requested and another resident entered room and assaulted R1. Community Care Licensing (CCL) received emails on 9/29/2023 indicating on the late evening of 9/27/2023/early morning of 9/28/2023 a resident (R2) had entered R1's room through the apartment door and picked up a shoe and hit R1 in the leg. Documents obtained from facility show R1's service plan indicate no cognitive impairment noted of 8/3/2023 based on current physician’s report.
Continue on LIC9099-C

Substantiated

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)

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Control Number 21-AS-20230929111257

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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Incident report received while at facility 10/2/2023 gives staff’s (S1) account of immediate statement confirming statements. LPA interview with R1 corroborates emails that staff did not lock apartment doors and another resident gained entrance and assaulted R1. LPAs interview with Executive Director corroborated R1's statement that the room entrances should have been locked. The facility was aware due to previous complaint 21-AS-20230623131207 that R1's doors should have been kept locked and were not.

During LPA's tour of facility on 10/2/2023 at 8:40am observed a sign on R1's door to keep locked at all times although LPA was able to open door as it was not locked. As this is a repeat violation of same deficiency a civil penalty in the amount of $250.00 will be applied. Allegation, Personal rights violation 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.

***$250.00 Civil Penalties for repeat violation

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 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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Control Number 21-AS-20230929111257

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: 10/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/03/2023 Section Cited HSC 1569.269(a)(5)(6)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Executive Director 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 10/3/2023.
	8 9 10 11 12 13 14	Based on records review, observation and interviews with Executive Director Joseph Hansen, staff, & resident, facility did not ensure the health and safety of clients in care by not following proper protocols in place or securing R1’s doors were locked	8 9 10 11 12 13 14	***$250. Civil Penalties for repeat violation
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC9099 (FAS) - (06/04)

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