496803698-5-9-2024-21-AS-BMOS-D58PFJ-20240513111650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 05/09/2024
Date Signed: 05/09/2024 03:26:54 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
05/02/2024 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20240502092820

FACILITY NAME:	VINEYARD AT FOUNTAINGROVE, THE		FACILITY NUMBER:	496803698
ADMINISTRATOR:	ANTONETTE EDWARDS		FACILITY TYPE:	740
ADDRESS:	200 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 544-4909
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	64	CENSUS: 44	DATE:	05/09/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Antonette Edwards, Administrator & Jeff Putnam, Regional Special Operations & Sales and, Nurse Consultant Jennifer Rice.		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are not ensuring residents have had their annual medical assessments

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and delivered findings regarding the allegation listed above and met with Administrator Antonette Edwards and Director of Sales and Marketing, Jeff Putnam & Nurse Consultant Jennifer Rice.

During investigation LPA reviewed documents and conducted interviews.

Staff are not ensuring residents have had their annual medical assessments- Complainant alleges residents are not getting updated annual physician’s reports as required. Per regulation 87705 ( c)(5) residents with a dementia diagnosis shall have an annual medical assessment. Documents obtained from facility indicate residents R1-R11 all have a dementia diagnosis on medical assessment’s and are between two and six years over due for annual medical assessments.

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: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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-20240502092820

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: 05/09/2024

NARRATIVE

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LPAs interview with Regional Director of Sales and Marketing & Nurse Consultant revealed the Health Services Director is responsible for scheduling doctors appointments with resident’s to get updated 602’s and due to the continued turn over rate, of that and other position’s in the last year to two years, residents have not been scheduled for new medical assessments. Allegation, Staff are not ensuring residents have had their annual medical assessments is found to be 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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240502092820

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: 05/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/10/2024 Section Cited CCR 87705(c)(5)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.	1 2 3 4 5 6 7	Administrator agrees to review policies and procedures with staff who oversees annual medical assessments and provide proof how facility will ensure medical assessments (602’s) are updated annually to CCL no later than POC due date, 5/10/2024.
	8 9 10 11 12 13 14	This requirement was not met based on interviews with Regional Dir of Sales & Marketing and record review of R1-R11 602's all having dementia dx & being 2-6 years over due, This is an immediate risk to health and safety.	8 9 10 11 12 13 14	As well, Administrator agrees to send in proof of renewed medical assessment for resident R1 – R11 by 5/30/2024 to clear POC.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC9099 (FAS) - (06/04)

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