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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 06/04/2024
Date Signed: 06/04/2024 02:20:28 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-20240521215956
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: 41DATE:
06/04/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Irene Hernandez, Regional Vice PresidentTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility does not have adequate staffing
Staff do not timely answer the facility telephone
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint findings regarding the allegations listed above and met with Irene Hernandez, Regional Vice President as Administrator was not available.

Facility does not have adequate staffing – Complainant alleges lack of staff throughout the facility including unmanned front desk throughout the day. Facility documents obtained on 5/23/2024 and interview with S1 & S2 revealed this 2-sided full dementia facility currently has 43 residents, of which 8 are 2 person assists and 35 are one person assist. Facility has 2 med techs on AM & PM shifts, one on each side. There is approximately 4 caregivers on AM & PM shifts (2 on each side) with hopes of a floater each day on each shift, and 2 caregivers for the nigh time (1 on each side). LPAs interviews revealed concluding information that facility is short staffed and makes attempts to hire. LPAs interview with S1 revealed There has not been a full time receptionist since end of April to May 20, 2024.
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: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
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-20240521215956
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: 06/04/2024
NARRATIVE
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 Title 22 regulation 87411(a) states, “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Therefore, the allegation Facility does not have adequate staffing is Substantiated.

Staff do not timely answer the facility telephone – Complainant alleges outside parties are unable to reach facility. On 5/22/2024 LPA Hansen attempted to contact facility at 11:53am and 11:58am and again on 5/23/2024 at 7:25 am & at 11:55 am and was given an operator message “the number has been disconnected or is no longer in service". During complaint investigation visit on 5/23/2024 LPA was informed by staff (S1) the phone’s have not been working since the morning of 5/20/2024 and the facility has reached out to the phone company (back east) that oversees the building phone service to get the problem solved. Staff also informed, there has not been a full-time receptionist since end of April until May 20, 2024. During visit on 5/23/2024 at approximately 3:00 pm, facility phone system began to operate, Therefore, the allegation Staff do not timely answer the facility telephone is Substantiated.

Based on LPA’s observations, interviews conducted, and records obtained, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Appeal Rights Given

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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240521215956
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: 06/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2024
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by licensee as evidenced by:
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Regional VP agrees to submit self certification stating that they are hiring additional staff and a self certified statement of how they will prevent this from happening again by POC due date of 06/05/2024. Once staff is hired, proof of updated staff schedule to be provided to LPA.
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Based on records review, observation, and interviews with staff, facility did not ensure staff is sufficient in number to meet residence needs by having 43 residents with 8 of whom are 2 person assist and only having 2 caregivers on each side during AM & PM shifts (with hopes of a floater) and only 1 Med Tech on each side, which poses/posed an immediate health, safety or personal rights risk to persons in care.
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Regional VP has informed facility has hired 4 part time staff receptionists, 3 additional caregivers & 1 additional med tech.
Type B
06/05/2024
Section Cited
CCR
87311
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All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. This requirement has not been met by:
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Facility has repaired the phone system and it appears to be working along with hiring 4 part time receptionists, along with other staff to cover all shifs.

Deficiency is cleared.
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Based on interviews and observations, the licensee did not comply with the section cited above by telephone system not functioning adequately which poses a potential health, safety or personal rights risk to persons in care.
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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: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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