496803698-6-22-2023-21-AS-SHAN-CT2UZM-20230622160145

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:01:56 PM

Document Has Been Signed on 06/22/2023 04:01 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, 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: 45	DATE:	06/22/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Eric Perry, Administrator		TIME COMPLETED:	04:15 PM

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Licensing Program Analyst (LPA) Hansen was at facility conducting annual inspection and conducted case management. LPA met with Administrator Eric Perry. The purpose of this case management is to follow up on two self-reported incident reports submitted to Community Care Licensing (CCL).

CCL received a self reported incident report on 6/20/2023 reporting on 6/14/2023 at 11:44 R1 left facility through the southeast exit. At 11:50 am elopement procedure was started and staff located R1 down the street at the bus stop 16 minutes later, uninjured and was assisted back to the facility. R1 has a history of exit seeking and has a diagnosis of dementia. POA and PCP were notified.

While investigating R1 reported incident, LPA was informed R2 eloped from facility on 6/18/2023 and facility was notified of elopement when Hospital called to inform they had R2. Administrator informed LPA R2 had removed safety devices from east activities room window and eloped from the facility. Resident was gone for approximately an hour and a half before an individual came across R2 on the street and took to the hospital. Facility was unaware R2 had eloped. R2’s LIC 602 dated 12/27/2022 indicates resident cannot leave facility unassisted and has wandering behaviors. Facility is full dementia.

Facility was cited on 12/6/2022 and again on 1/17/2023 for the same citation mentioned above. (see copy, LIC 809-D)

On 6/22/2023 CCL received a self reported LIC624 & SOC 341 regarding an incident that occurred at approximately 10pm on 6/21/2023 where R3 came into R4’s bedroom and began looking through R4’s closet and then picked up R4’s belongings, when R4 asked to put them down R3 began tugging on R4’s head pillow. When R4 reached up to grab pillow R3 grabbed R4’s arm and squeezed. R4 yelled and R3 backed away. All appropriate parties were contacted including, Law enforcement & EMS. R4 told police they did not want to press charges due to R3’s dementia diagnosis. Facility posted staff at door of R4 for the rest of the night.

Continue on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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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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
	VISIT DATE: 06/22/2023

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R4 was not injured other then bruising to the arm. Facility conducting care conference with R3’s family & physician. Administrator has informed family has agreed to private care giver for 24/7 staff with R3 due to 2nd incident in less then a month.

Civil Penalties are being assessed in the amount of $1000.00 due to a 3^rd 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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/22/2023 04:01 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: 06/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/23/2023 Section Cited CCR 87705(b)(2)	1 2 3 4 5 6 7	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.	1 2 3 4 5 6 7	Facility to ensure all exits have working/efficient delayed egress and all windows have alerting systems (not just bedrooms. Administrator provided proof of elopement training for staff 6/21/2023. Staff to check on 2 AWOLS every hour and sign & date log sheet. Administrator agrees to submit LIC9098 that the staff understand the regulation.
	8 9 10 11 12 13 14	Based on record review, self-incident report dated 6/20/2023, and interviews conducted with Administrator, R1 eloped without staff knowledge on 6/14/2023. And interview with Admin. R2 who has exit seeking behaviors eloped for over an hour & a half. 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.	8 9 10 11 12 13 14	*****Civil penalties are issued today in the amount of $1,000.00 for 3rd repeated violation within 12 months.
	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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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