496803698-9-21-2023-21-AS-BMOS-D47T4F-20240410142349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 09/21/2023
Date Signed: 09/21/2023 02:38:41 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
08/03/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20230803084501

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:	09/21/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Christina Cruz, Assistant Executive Director & Kimiyo Jones Health Services Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Insufficient staffing to meet the needs of all residents
Facility not able to supply appropriate incontinent care products
Staff are mismanaging residents medication
Staff are not following resident's care needs
Staff are not providing activities for residents
Facilities transportation not operational

INVESTIGATION FINDINGS:

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LIcensing Program Analyst (LPA) Hansen 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 Christina Cruz, Assistant Executive Director & Kimiyo Jones Health Services Director.

Insufficient staffing to meet the needs of all residents – Facility not able to supply appropriate incontinent care products- Complaint alleges on the PM shift (2pm – 11:30pm) there is one staff for 33 residents on the east side and one staff for 11 residents on the west side of the dementia facility, with an additional staff that is to help both sides but does not. LPA conducted interviews with 6 staff, staff (S3) informed in July/August,2023 many days from 2-10:30pm there was only 1 caregiver on each side (east & west) to take care of the residents needs, sometimes there was a floater staff if the facility could get to come in early. Interview with S1 on 9/9/2023 corroborate S3 but included 1 medication technician for the entire building during hours of 2pm to 10:30pm. 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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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 9

Control Number 21-AS-20230803084501

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: 09/21/2023

NARRATIVE

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Documents obtained from facility show in July and the beginning of August 2023 there was 27 residents on the East side of the building & 18 residents on the West side, 35 one person assists & approximately 9-10 (2) person assists, 2 use Hoyer lifts and 1 is on oxygen. (I2 -Co complainant) reported being requested to lift and carry a resident so that the staff could assist in dressing them and managing the residents catheter bag. During tour of facility on 8/9/2023 at approximately 1:45pm, LPA and S1 observed on east side hallway R2 went to the bathroom on the floor in other residents’ room and in the hallway floor. R2 had also wiped fecal matter on other residents’ door (see pictures). There was fecal matter on resident’s pants, hands, and shoes. There was no care staff in sight. While opening another complaint at facility on 8/25/2023 at approximately 10:40am with LPA Coppo, LPA’s toured both sides of facility and observed on the west side dining/kitchenette 4 residents and 2 residents in the courtyard - LPA's did not observe any staff. On the east side of the (locked) facility, walking the entire unit, LPA's did not observe any staff on this side either, other than a Med Tech leaving the med room for break. As LPA's were leaving the unit a caregiver R4 walked up and stated they were in a resident room with another staff changing a 2 person assist resident. Based on interviews, observations, & record review, LPA was able to obtain a preponderance of evidence that facility has insufficient staffing to meet the needs of all the residence.

Complaint also alleges facility is not able to supply appropriate incontinent care products, the families pay for the facility to have incontinence products and the facility is out of them. On 6/27/2023 LPA conducted inspection of facility and was informed by R3 the depends being used are cheap, do not fit & are scratching them. On 7/21/2023 LPA received call from Individual ( I4) who was at the facility and observed resident wearing incontinent products that do not fit and are leaving marks on resident after requesting many times for briefs that fit. On 8/9/2023 LPA was informed by S1 the incontinence company that delivers the product stopped for approximately a month at the end of June /beginning of July. They were saying there was a due bill that was not paid, although the facility never received this bill. S1 went to the store and bought them two different times. (receipt’s for 6/29/2023 - briefs for residents - men & women) and again on 7/16/2023). LPA contacted Incontinence supplier on 9/18/23 who informed the facility was placed on a hold in March 2023 due to lack of payment, in April with a verbal agreement they began shipping again. Although facility attempted to provide incontinence products for the residents when the company that provides this product for the facility stopped due to lack of payment, the product did not appropriately fit. Based on interviews, observations, & record review, LPA was able to obtain a preponderance of evidence that facility is not able to supply appropriate incontinent care products during reported time of allegations. The allegation is Substantiated.
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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 21-AS-20230803084501

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: 09/21/2023

NARRATIVE

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Staff are not following residents care needs- Complainant alleges in July staff could not find a resident and eventually found on the floor in the bathroom was pants off, in urine and believes this occurred due to no one conducting regular checks. Co-complainant provided observed corroborating experience of resident being unbathed in the same clothes from the last visit and once found stool in the bathroom trash can. Many times co-complainant found resident with urine soaked clothing that had soaked through unchanged depends that often had feces in them as well. There were many times co-complainant helped residents eat & put clothing on. LPA visited the facility on 6 different occasions finding only 1 or 2 care staff on each side to care for the needs of 9-10 residents that are 2 person assists. The preponderance of evidence standard has been met; therefore, the above allegations, there is insufficient staffing to meet the needs of all residents, the facility not able to supply appropriate incontinent care products, & staff are not following residents care needs are Substantiated.

Staff are mismanaging residents’ medication – Complainant alleges expired medications including narcotics from residents who passed away are left in drawers. On 8/8/2023 LPA conducted inspection of facility and observed S2 in east unit med room, on shelf above desk were 3 bubble packs of expired medications that had expiration dates of 6/27/2023, 7/8/2023, 8/1/2023. LPA also observed a large garbage bag containing expired medications & medications from previous (deceased?) residents needing to be destroyed (see pictures taken). On 8/9/2023 LPA was at facility opening complaint and while touring the facility at approximately 1:45 pm observed quarterly Audit of medication room. Auditor informed there were 11 expired narcotics and 2 medications from a resident that deceased a month ago, that had not been destroyed. LPA obtained copy of full audit that revealed: Multiple expired medications found, both PRN and scheduled medications and eye drops. Open dates are inconsistent on medications, eye drops, inhalers, & nasal sprays. Records obtained indicating staff signatures missing on Medication Administering Records (MAR)’s for narcotics. The preponderance of evidence standard has been met; therefore, the above allegation, staff are mismanaging resident’s medication is Substantiated.
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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 21-AS-20230803084501

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: 09/21/2023

NARRATIVE

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Staff are not providing activities for residents - Complainant alleges there are no activities for the residents on the west side of the facility. LPA obtained facility activities calendar for August 2023 that indicates 4 to 5 different activities per day. LPA conducted 6 facility visits on 7/13/23,8/8/23, 8/9/23,8/25/23,8/31/23, & 9/12/2023 and only observed group discussions on one side of the (two units) facility in an activities room and bingo to be conducted once. On 8/25/23 visit to facility LPA’s Hansen & Coppo did not observe any activities being conducted on either side of the facility. LPAs interview with complainant on 8/4/2023 revealed there were only approximately one and a half hours of activities per day on the east side of the facility. Per letter 8/24/23 from co-complainant I2 of 21-AS-20230803084501 R1 was to be taken to activities regularly but this never happened. Interview with S1 on 8/31/23 acknowledged new activities director 5/2023 has not been as productive in the amount of hours or different options families/residents have been given. The facility has not been successful in this area. The preponderance of evidence standard has been met; therefore, the above allegation, staff are not providing activities for residents is Substantiated.

Facilities transportation not operational-Complainant alleges facility bus is broken and unable to be used by residents. LPA obtained documents of facility van showing registration expired on 6/1/2023 and was not renewed until 8/24/2023. LPA conducted 3 staff interviews, resident interview, & outside party interviews. Interview with Administrator Eric Perry on 7/5/2023 regarding transportation stated “ I have been here for about 2 months now and have not been made aware of any transportation issues.”, conflicts with interview with staff (S1) on 8-9-2023 who informed “The registration lapsed on June 1, 2023 and at the same time the lift broke in it. The lift goes down but has an issue getting back up. (see copy of expired registration) it is not registered as yet because they (DMV) said we owe more money. 7/5/2023 interview with I1“ (families) are paying for the transportation as it is part of the agreement but the facility is not providing the accommodation. The family had to hire a private caregiver to accompany resident on public transportation to medical appointments. LPA received copy of current vehicle registration and service receipt confirming 9-9-23 that facility van registration became current on 8/24/2023 & lift was fixed on 8-29-23. The preponderance of evidence standard has been met; therefore, the above allegation, Facilities transportation not operational is Substantiated.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 9

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
08/03/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20230803084501

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:	09/21/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Christina Cruz, Assistant Executive Director & Kimiyo Jones Health Services Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Multiple residents have wandered from facility due to staff neglect
Staff are not providing adequate food service to residents
Facility dishwasher is in disrepair

INVESTIGATION FINDINGS:

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LIcensing Program Analyst (LPA) Hansen 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 Christina Cruz, Assistant Executive Director & Kimiyo Jones Health Services Director.

Multiple residents have wandered from facility due to staff neglect – Complainant alleges there have been multiple residents who have gotten out of the facility since May. Co-Complainant informed the frequency of residents escaping the facility and ending up near the road is disturbing. Per I5 they alerted staff when they noticed such instances, but unfortunately, this seemed to happen so often that they eventually stopped notifying the staff. LPA conducted interviews, 3 interviews with staff, made observations, & reviewed records. Investigation revealed complainant was present in the building in the month of 7/2023.

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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 21-AS-20230803084501

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: 09/21/2023

NARRATIVE

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Records indicate facility had two residents who eloped from the facility, one on 6/14/23 & the other on 6/18/23 where staff lost visual contact with residents outside of the facility and a search had to be conducted to return the residents and were cited for both events. Based on interviews, record review, and observations LPA is not able to prove or disprove multiple residents have wandered from facility in the time period the complaint alleges. Therefore, the allegation is Unsubstantiated.

Staff are not providing adequate food service to residents – Complainant alleges residents are only being given frozen vegetables when they should be provided fresh. LPA conducted facility visits on 8/8/23, 8/9/23,8/25/23,8/31/23, & 9/12/2023 and observed fresh vegetables in facility refrigerator and being served. On 8/9/2023 LPA was told by facility executive chef, “Every Wednesday the facility receives food delivers”. LPA requested and reviewed service purchase orders dated :5/24/23, 5/31/23, 6/7/23, 6/14/23, 6/21/23, 6/28/23, 7/5/23, 7/13/23, 7/19/23, & 8/2/23. Purchase orders showed facility received the following fresh vegetables: lettuce, spinach, cucumbers, cauliflower, squash, zucchini, onions, carrots, tomatoes, shallots, cabbage, asparagus, romaine hearts, avocado’s, and swiss chard. Based on record review, interviews with staff, and observation, LPA is not able to prove or disprove facility staff are not providing adequate food service to residents. Therefore, the allegation is Unsubstantiated.

Facility dishwasher is in disrepair – Complainant alleges for approximately a week staff were using a bucket to catch the water leaking from the dishwasher. LPA conducted visit of facility on 8/9/2023 and observed facility dishwasher in working order. LPA was informed by Executive Chef Betty Kennedy that there was a leak coming from the dishwasher, which was fully operational, it was fixed. LPA interviewed Environmental Services Director (ESD) James Brady stating, Yes there was a motor issue in the dishwasher /leak in May and it was fixed the same day and then a week later it broke again, the dishwasher was functional but there was a continuous minor drip/leak. Repair Service was called and they were able to come out & replace the Booster Tank for the leak once they received the part the last week of July. LPA obtained service invoices indicating facility responded to repairs in a timely manner. Based on record review, interviews with staff, and made observation, Department is not able to prove or disprove facility dishwasher is in disrepair. 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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 21-AS-20230803084501

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: 09/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/21/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	POC As of mid August Licensee has hired a new RN , 2 new LVN's (4 total - one being a psych tech) with one more to come & 7 new caregivers (total 27).
	8 9 10 11 12 13 14	Based on LPA’s observations, interviews, & records reviewed showing there was a lack of care staff at the facility between 6/2023 & 8/2023 to care for the needs of the residents and lack of appropriate incontinent products for the residents as required in care plans. This is a potential health and personal rights risk to residents in care.	8 9 10 11 12 13 14	POC cleared at time of visit.
Type B 09/22/2023 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	87705 (c) (4) Care of Persons with Dementia. There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement has not been met as evidence by:	1 2 3 4 5 6 7	As of mid August facility has hired a new RN, 3 additional LVN’s, & 7 additional caregivers to support each resident’s physical, social, emotional, care needs.
	8 9 10 11 12 13 14	Based on LPAs observation, statements, and record review the facility failed to ensure adequate staffing to meet residents care needs which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	POC cleared at the time of this visit.

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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 21-AS-20230803084501

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: 09/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/22/2023 Section Cited CCR 87465(i)	1 2 3 4 5 6 7	87465(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident.	1 2 3 4 5 6 7	Administrator to ensure that facility is following required destruction procedures at all times per Title 22 regulations and submit self-certification that they reviewed regulation 87465(i) by POC due date.
	8 9 10 11 12 13 14	Based on observation, record review, & interview, facility did not comply with the regulation above by not destroying medications of former residents upon separation from the facility. Which is a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14	LPA observed medication room not containing expired medications or medications belonging to residents no longer at facility during today's visit.
Type B 09/29/2023 Section Cited CCR 87219(a)	1 2 3 4 5 6 7	87219 Planned Activities - (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit their plan to ensure residents are provided daily activities per regulation. Detailed plan to be submitted to Community Care Licensing by POC due date 9/29/2023.
	8 9 10 11 12 13 14	Based on LPA’s observations and statements received, Licensee did not ensure the regulation above due to not having daily activities for residents as required. This is a potential health and personal rights risk to residents in care.	8 9 10 11 12 13 14

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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 21-AS-20230803084501

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: 09/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/21/2023 Section Cited CCR 87312	1 2 3 4 5 6 7	87312 Motor Vehicles Used in Transporting Residents. Only drivers licensed for the type of vehicle operated shall be permitted to transport residents. The rated seating capacity of the vehicles shall not be exceeded. Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition.	1 2 3 4 5 6 7	POC : cleared at time of visit as facility has submitted proof of reinstated registration & receipt of van being fixed, along with email sent to families the fan is in use now sent 9/9/2023.
	8 9 10 11 12 13 14	This requirement has not been met by: Based on records review and interviews with S1 & I1, facility did not ensure transportation was maintained in a safe operating condition, as the registration lapsed for 3 months & the lift was not functional for the same duration. This is a potential health & safety risk to persons in care.	8 9 10 11 12 13 14	POC cleared at time of 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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

Page: 9 of 9