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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 09/12/2023
Date Signed: 09/12/2023 02:50:39 PM


Document Has Been Signed on 09/12/2023 02:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
496803698
ADMINISTRATOR:ERIC PERRYFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 43DATE:
09/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH: VP of Operations West Region, Rickay Hidalgo, Regional Dir of Operations/West Region, Edie Cano, Interim Administrator Joe Hansen, and Assistant ED/Marketing Dir. Christina Cruz.TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Hansen was at facility continuing investigation into a complaint and was informed of 2 medication errors. LPA met with VP of Operations West Region, Rickay Hidalgo, Regional Dir of Operations/West Region, Edie Cano, Interim Administrator Joe Hansen, and Assistant ED/Marketing Dir. Christina Cruz.

LPA received 2 self reported incident reports from facility reporting 2 insulin medication errors. The first medication error occurred on 09/04/2023 when LVN (S1) did not administer Resident (R1)’s 8:00AM insulin medication, as prescribed by physician. LVN notified primary care physician (PCP) same day but did not notify facility or family of missed routine insulin until 09/06/2023. When Health Services Director (HSD) was made aware of error two days later, they reported to PCP, although HSD was not aware family had not been notified and did inform today of incident, 9/12/2023. R1 had no adverse side effects from missed medication and remains at baseline.

The second error occurred on the morning of 09/06/2023 while licensed nurse (S1) did not dispense 11:30AM routine dose of insulin medication to R2, as prescribed by physician. At approximately 4:05PM HSD was made aware of missed medication not being given to R2 as prescribed by physician. Responsible parties and prescribing doctor was notified of medication error. LPA obtained copies of the in-house incident reports indicating medication errors.

*Immediate civil penalties in the amount of $250 are issued due to repeated citation within 12 months.


Interview with Regional Dir of Operations/West Region, Edie Cano informed facility has suspended S1 for 7 days and will review S1’s future with facility at that time.

The following deficiencies were observed (see LIC 809D) 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..

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2023 02:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2023
Section Cited
CCR
87465(a)(5)

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87465(a)(5)-Incidental Medical and Dental Care: The Administrator shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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(POC) shall include a self-certification of the regulation and training of ALL staff that administer medication. In addition, Licensee shall write a written statement on how future compliance will be met. S2 has been relieved of their duties.
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Based on two self-reports submitted by facility, a staff did not administer insulin medication to R1 & R2 as prescribed by their Physician which is an immediate Health and Safety risk to the resident(s) in care.
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*Immediate civil penalties in the amount of $250 are issued due to repeated citation within 12 months.

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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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
LIC809 (FAS) - (06/04)
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