496803698-2-26-2021-21-AS-KMOA-BZFLNL-20210325085431

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 02/26/2021
Date Signed: 02/26/2021 08:12:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2020 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200727120752

FACILITY NAME:	VINEYARD AT FOUNTAINGROVE, THE		FACILITY NUMBER:	496803698
ADMINISTRATOR:	EDWARDS, SUSAN		FACILITY TYPE:	740
ADDRESS:	200 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 544-4909
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	64	CENSUS:	DATE:	02/26/2021
		UNANNOUNCED	TIME BEGAN:	06:30 PM
MET WITH:	Tyler Mason-Executive Director		TIME COMPLETED:	07:00 PM

ALLEGATION(S):

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Staff are restraining residents
Staff are not reporting falls
Staff do not have proper training

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a televisit inspection, on 2/26/21 at approximately 6:30PM to deliver findings. LPA conducted the televisit with Executive Director, Tyler Mason. The inspection is being conducted by tele-inspection due to COVID-19. The reader is advised that the LPA did not physically make a site visit.

The LPA reviewed information provided by the reporting party(s). The LPA reviewed resident records (R1, R2, R3), including care plans, medical records, incidents, in-home health records, and medication records. LPA reviewed staff training records. The LPA conducted interviews with staff (S1, S2, S3, S4, S5) The investigation revealed that the staff have the training required. Staff have had training in resident transfers, and in caring for residents with dementia/memory loss. Residents have had elder abuse training as required, and have had training in responding to residents who fall or any resident incidents that may occur.
Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021

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-20200727120752

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VINEYARD AT FOUNTAINGROVE, THE	FACILITY NUMBER: 496803698
	VISIT DATE: 02/26/2021

NARRATIVE

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Staff(S4, S5) interviewed stated they did more than 40 hours training when they first started working, and additional medication training hours if assisting residents with medication. Staff stated that they do training all the time, it is ongoing. S1 stated that staff caregivers and medication technicians are trained to work with dementia residents. To assist the residents with their care needs, bathing, grooming, incontinence care, transfers, medication assistance, and other care services as needed. LPA interviewed staff that were able to provide information of their job duties, and the training provided to them which LPA observed in training records. All staff interviewed denied ever restraining a resident at any time. Staff stated to the LPA that they have not observed any resident(s) being restrained in any way, not by use of a wheel chair or anything else, and not by any other staff member. Staff interviewed had stated to the LPA that if a resident falls the resident is assessed for injuries by medication technicians, who have CNA training as well. Once the medication technician assesses the resident, emergency services/911 is called if needed for the resident, first aid is provided by the medication technician if needed, and documenting the incident is done by the medication technician staff. The incident being reported is determined by the administration staff as they are notified of all incidents. S1, Administration staff, stated to the LPA that all incidents requiring to be reported are completed and reported to all required parties. S1 stated that all residents responsible parties are notified of incidents that occur with the residents. LPA was provided documents of residents and reported incidents to review as requested.

Based on LPAs observations, record reviews, interviews with staff, and conflicting information obtained from other related parties, there is insufficient information to prove or disprove the allegations of Staff are restraining residents, Staff are not reporting falls, and Staff do not have proper training. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated.
No citations issued this visit.
Exit interview completed.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021

LIC9099 (FAS) - (06/04)

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