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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 05/20/2024
Date Signed: 05/20/2024 02:50:40 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
05/16/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20240516095437
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: 44DATE:
05/20/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Buisness office Manager Serina Barreda and Nurse Consultant Jennifer Rice.TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are not managing resident's medication properly
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 Business office Manager, Serina Barreda and Nurse Consultant Jennifer Rice as Administrator was not available.

During investigation LPA made observations, reviewed documents and conducted interviews.

Staff are not managing resident’s medication properly- Complainant alleges residents are missing medications and the medication room is not in compliance. Documents obtained from facility indicate on 5/9/2024 resident R1 did not received their 4:30pm insulin dosage. Doctors orders dated 4/15/2024 indicate R1 is to have blood sugar checks and prior to each meal three scheduled insulin doses per day. Record review and Interview with Administrator on 5/17/2024 confirmed staff (S1) left facility without providing/administering resident’s scheduled insulin and or designating other staff to administer.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
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 3
Control Number 21-AS-20240516095437
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: 05/20/2024
NARRATIVE
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On 5/20/2024 LPA toured facility with Nurse consultant and observed In east side medication room, opened chocolate pudding in med cart for crush orders and pre-poured medications.

Allegation, Staff are not managing resident’s medication properly 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.

LPA is issuing a citation today for medication error and Civil Penalties for a 2nd repeat violation in less than 12 months.

****Civil Penalties are being assessed in the amount of $250 due to a second repeat citation for deficiency last cited on 9/12/2023.

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: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240516095437
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: 05/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2024
Section Cited
CCR
87465(a)(5)
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87465(a)(5) Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed.
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LPA is requesting facility to provide name of training company by POC due date of 5/21/2024 & for facility to conduct Internal medication training from person outside of organization to all staff providing Insulin medication on all shifts and submit log in sheet with written staff names ..
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Based on special incident report submitted by facility, staff did not administer 4:30pm insulin on 5/9/2024 medication to R1 as prescribed by their Physician, prior to each meal, and LPA's observations of pre-poured medicaitons in cart with opened pudding which is an immediate Health and Safety risk to the resident(s) in care.
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& signatures w/ date and signed by trainer by POC due date 5/31/2024 to clear POC.

Consulting nurse informed med tech training meeting prev. scheduled for 5/21/24 due to inconsistancies of medication administration.
*** Immediate Civil Penalties for $250. for 2nd repeat violation of same deficiency in less than 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: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
LIC9099 (FAS) - (06/04)
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