496803698-5-23-2024-21-AS-BMOS-D5QN99-20240529101534

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 05/23/2024
Date Signed: 05/23/2024 04:17:59 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
05/21/2024 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20240521080908

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: 43	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Buisness office Manager Serina Barreda and Nurse Consultant Jennifer Rice.		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff are not current on required trainings

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 (BOM), 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 current on required trainings- Complaint alleges care staff’s required CPR & First Aid trainings are not current, along with dementia training, and medication training. Sample review of three (3) Medication Technician’s(Med Techs)(S1-S3) and six (6) caregivers(S4-S9) files reviewed by LPA, BOM, and Nurse Consultant on 5/23/2024 revealed all dementia training was either insufficient or was not completed, medication training was insufficient or not completed, & only one AM caregiver (S4) had current first aid. Therefore, the allegation, Staff are not current on required trainings is found to be Substantiated.
Continue on LIC9099C

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: 05/23/2024

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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240521080908

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: 05/23/2024

NARRATIVE

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A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were observed (see LIC 9099D) 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: 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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240521080908

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: 05/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/21/2024 Section Cited HSC 1569.62(a)	1 2 3 4 5 6 7	1569.62 (a) Training requirements; continuing education-The director shall ensure that licensees, administrators, and staff of residential care facilities for the elderly have appropriate training to provide the care and services for which a license or certificate is issued. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator & BOM agree to submit proof of required, current dementia care training, medication trainining, and required CPR & 1st Aid certification per regulation for S1-S9 to CCL by POC due date 6/21/2024.
	8 9 10 11 12 13 14	Based on record review and interview with BOM & Nurse Consultant, required trainings of dementia care were not current for staff S1-S9, medication traing was not current for S1-S3, and CPR & 1st Aid was not current for S1-S9 other then S4. This is a potential risk to the health and safety of residents in care	8 9 10 11 12 13 14
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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: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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