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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 02/20/2024
Date Signed: 02/20/2024 03:18:42 PM


Document Has Been Signed on 02/20/2024 03:18 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:JOSEPH HANSENFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 47DATE:
02/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Joseph Hansen, Administrator TIME COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced at facility to conduct a case management and met with Administrator Joe Hansen. The purpose of this case management is to follow up on a self-reported incident report of resident elopement submitted to Community Care Licensing (CCL) on 2/1/2024.

CCL received a self-reported incident report that occurred on the morning of 1/29/2024. It was reported at approximately 9:45am staff spoke with resident (R1), then approximately 10 minutes later at 9:55am during checks R1 was unable to be found after full check of facility by all available staff. Administrator and RCD searched surrounding area and located R1 approximately 15 minutes later, 3 blocks away, uninjured and was assisted back to facility. Report indicates R1 removed safety devices from vacant room window, unarming alarm system and eloped from facility. R1 has a history of exit seeking and physician’s report (602) dated 12/27/2022 indicates resident cannot leave facility unassisted. Facility is being cited for not having Physician’s Report updated for Dementia residents within a 12 month period (see LIC809-D) Regulation 87705( c)(5). LPA and Administrator toured facility at approximately 2:30 pm and observed hallway fire doors shut. Administrator informed LPA the hallway fire doors are malfunctioning due to broken magnetic devices to hold them open and close them if there was a fire (see LIC809-D).

Facility was given civil penalties on 6/22/2023 for elopement of R1 on 6/18/2023 due to prior citations of residents on 1/17/2023 and again 12/6/2022 for the same citation mentioned above.

Civil Penalties are being assessed in the amount of $1,000. due to a continued 2nd repeat violation of 87705(b)(2) in less than 12 months.

*******Total Civil Penalties issued today in the amount of $1,000.00

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: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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 02/20/2024 03:18 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: 02/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2024
Section Cited
CCR
87705(b)(2)

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87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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Facility to ensure all exits have working/efficient delayed egress and all windows have alerting systems. All empty rooms to be kept locked & Admin/facility to provide activities specific for R1’s needs. Administrator to provide proof of elopement training for staff.(by EOB 2/23/2024) Staff to check on AWOLS every hour and sign & date log sheet. Administrator agrees to submit LIC9098 that the staff understand the regulation.


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Based on record review, self-incident report dated 2/1/2024, and interviews conducted with Administrator, R1 eloped without staff knowledge on 1/29/2024. The facility did not comply w/section above to address behaviors such as wondering for R1 which poses an immediate Health, Safety risk to residents in care.
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 *****Civil penalties are being issued today in the amount of $1,000.00 for 2nd repeated violation 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: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/20/2024 03:18 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: 02/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/29/2024
Section Cited
CCR
87705(c)(5)

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 87705(c)(5) Care Persons with Dementia - Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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Facility agrees to send in proof of current medical assessment for resident R1 and statement they understand regulation.
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This requirement was not met as evidenced by: during inspection of R1's records it was observed R1 did not have a current Physician report- last report in file was dated 12/27/2022 and not within regulation. This is a potential risk to the health and safety of residents in care
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POC due date 12/29/2024 to CCL.
Type B
03/20/2024
Section Cited
CCR87303(a)

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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.
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Administrator to fix and send copy of repair receipt for all hallway etc..fire doors to CCL by POC due date 3/20/24
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Based on LPA and Administrator observation, the licensee did not comply with the section cited above in that hallway fire doors are malfunctioning due to broken magnetic devices, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
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