496803698-1-23-2024-21-AS-VBEI-CZUUJD-20240126143722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 01/23/2024
Date Signed: 01/23/2024 11:19:23 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
08/24/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20230824155633

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: 46	DATE:	01/23/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Joseph Hansen, Executive Director		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facilty did not ensure residents room was clean, safe and sanitary

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. During the course of this investigation LPA conducted interviews, made observations, and obtained documents regarding the allegation. LPA met with Joseph Hansen, Executive Director.

Facility did not ensure residents room was clean, safe and sanitary – Complainant alleges rooms are not cleaned by staff leaving vomit, feces and or urine on the floor, bedding, furniture, and floor, urine soaked clothing on the floor that had feces in them as well as stool in bathroom trashcan on one occasion. Interviews with staff revealed during that time period housekeeping staff was minimal, lacking the ability to properly clean facility. Outside party confirmed cleaning was not available for a day or two after request, which was sometimes completed by maintenance.

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: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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-20230824155633

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: 01/23/2024

NARRATIVE

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Outside party confirmed during interview, at times, upon arrival, cleaning was required to ensure R1’s room was sanitary; this cleaning was performed by outside party. R1 was no longer present in facility at time of complaint. LPA was in building on 8/25/2023 for complaint and did not observe residents’ rooms being unclean or unsanitary. Documents and photo obtained from investigation verify staff did not ensure residents room was kept clean, safe, and sanitary. Therefore this allegation is Substantiated.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

.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: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

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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
08/24/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20230824155633

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:	DATE:	01/23/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Joseph Hansen, Executive Director		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Lack of Care and Supervision resulting in severe malnutrition and dehydration
Facility failed to meet the care needs of residents in care
Staff did not safe guard resident's personal belongings

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 allegations. LPA met with Joseph Hansen, Executive Director.

Lack of Care and Supervision resulting in severe malnutrition and dehydration – Complainant alleges resident (R1) lost 35 pounds in 2 and a half months at facility as a result of severe malnutrition and dehydration due to lack of care and supervision by staff. R1 was admitted 4/12/2023 and responsible party discharged R1 on 6/26/2023 due to R1s decline, 1:1 was implemented for R1 on 5/24/2023. Based on record review and interviews R1 has a history of acid reflux/vomiting & urinary tract infections (UTI’s). LPA obtained ongoing communication with two identified doctors regarding R1s change of condition and observed decline between April and June of 2023.
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: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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-20230824155633

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: 01/23/2024

NARRATIVE

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Interviews and record review revealed R1 was seen by doctor on multiple occasions not limited to, UTI symptoms, vomiting, medication refusal and behaviors. Care notes reviewed also indicate R1 regularly refused to eat facility meals and refused ADL’s. Interview with outside party confirmed that the facility was actively offering meals and water. LPA was unable to obtain any documentation of diagnosis related to malnutrition and dehydration to support the allegation. LPA determined based on evidence obtained, R1 had a decline but was unable to obtain information to support the facility lacked care and supervision resulting in severe malnutrition and dehydration. Therefore, the allegation is Unsubstantiated.

Facility failed to meet the care needs of residents in care – Complainant alleges bed did not have sheets on it, R1 was not changed or bathed for days, and incontinent care was not met. Interviews revealed R1 had difficulty sleeping and would take the sheets off of the bed. Interviews also revealed staff would conduct regular checks and to ensure incontinent care was being met. Care notes revealed refusal of bathing and incontinent care. Interviews confirmed staff made multiple attempts to assist R1 with ADL’s. Record review indicated communication with doctor regarding behaviors and resistance of care. R1 had medication changes and 1:1 staff was implemented to assist. Responsible party was notified regarding the facility’s challenges and R1 refusing care. LPA was unable to obtain evidence that the facility failed to provide care and was actively communicating with doctor and responsible party about R1s decline. Therefore, the allegation is Unsubstantiated.

Staff did not safe guard resident's personal belongings – Complainant alleges personal bedding, clothes, and throw rugs would disappear when facility did laundry. Interviews with staff revealed, due to the nature of residents’ condition sometimes residents wear things and take them off someplace else and some residents go into other residents’ rooms and pick belongings up, wear it, or leave it elsewhere. Interview with outside party was unaware of any missing items. LPA was unable to obtain supporting evidence that belongings disappear when facility does laundry and or obtain documentation of missing items from facility, although LPA has been informed a process and binder have been implemented as of 1/5/2023. Although the allegation of staff did not ensure that resident’s personal belongings are safeguarded, may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, 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: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230824155633

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: 01/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/26/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 (a) Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors…	1 2 3 4 5 6 7	POC: Facility hired additional staff 7 additional caregivers (total 22) & 3 full time housekeepers. One on each side 7am until 3:30 pm & then Care staff does any cleaning needs until 7am.
	8 9 10 11 12 13 14	This requirement was not met based on evidence by picture of R1 in bed with vomit on R1 and bed. Interviews conducted with staff and outside parties indicating lack of staff to clean room. This is a potential risk to the health and safety of resident’s in care.	8 9 10 11 12 13 14	POC has been cleared at today’s visit.
	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: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

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