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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 05/23/2024
Date Signed: 05/23/2024 04:02:22 PM


Document Has Been Signed on 05/23/2024 04:02 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:ANTONETTE EDWARDSFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 43DATE:
05/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Buisness office Manager Serina Barreda and Nurse Consultant Jennifer Rice.TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced at facility to conduct a case management and met with Buisness office Manager Serina Barreda and Nurse Consultant Jennifer Rice. 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 5/21/2024.

CCL received a self-reported incident report that occurred at approximately 1:30pm on 5/19/2024. Report indicates staff received a call from local hotel approximately a block away that a resident (R1) was in their lobby. Manager on duty went and escorted R1 back to facility. R1 was assessed finding uninjured. Report indicates R1 may have left via an employee entrance that has a delay in activating the lock after a code has been entered. Facility has informed all staff, they must stay at any door until it locks. R1’s current physician’s report (602) indicates resident cannot leave facility unassisted.

Civil Penalties are being assessed in the amount of $1,000. due to a 3rd repeat violation of 87705(b)(2) in less than 12 months. Prior violations of this regulation were cited on 2/20/2024 & 6/22/2023.

*******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: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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 05/23/2024 04:02 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: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2024
Section Cited
CCR
87705(b)(2)

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87705(b)(2) 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...
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Facility to ensure all exits have working/efficient delayed egress and all windows have alerting systems. New alarms have been put on east & west lobby door & east & west employee hallway doors and employee hallway exit door to outside that is at back of building. & looking into locking exterior perimiter. Will inform CCL
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Based on record review, self-incident report dated 5/21/2024, and interviews conducted with BOM & Nurse consultant R1 eloped without staff knowledge on 5/19/2024. 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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These doors prior had no alarms only key codes that when accessed did not reingauge for 15 seconds.

*****Civil penalties are being issued today in the amount of $1,000.00 for 3rdd 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: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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