<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:00:30 PM


Document Has Been Signed on 08/13/2024 03:00 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: 38DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Nancy Steers-Crist Interim AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual inspection of facility. LPA met with Interim Administrator, Nancy Steers-Crist (Operations Specialist from CoBridge). There is a total of 38 residents at this full memory care facility. There are 7 residents currently on Hospice.

LPA toured the facility on 8/13/2024 at 8:30 AM with Interim Administrator. LPA observed all exits were unobstructed. Facility fire extinguishers, twelve of them (12 of 12), were last serviced 7/2024. Fire department last inspected 7/24/2024-no violations noted on inspection date. Smoke alarms are hard wired with combination carbon monoxide detectors. Resident bathrooms have grab bars as required and non-slip flooring in showers. The food supply was sufficient during today's inspection. Hot water temperature measured between 105.2 degrees F and 111.3 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 8 of 8 resident’s bathrooms while touring facility. During tour of resident rooms LPA & Interim Administrator observed scissors, razors, tweezers, clippers, & hydrogen peroxide along with other personal hygiene products accessible to residents in multiple rooms (see pics)(see LIC809-D). While touring kitchen pantry had a large hole cut out in ceiling (see pics) and LPA discovered stove oven pilot light is having issues staying lit (see pics)(see LI809-D) Resident medications are kept locked and secured in a designated medication room to ensure they are kept inaccessible to residents in care, along with Medication Technicians using two medication carts to disperse medications, that were locked when checked at 11:10am on 8/13/2024.

LPA initiated a file review of five resident files and five personnel files but were unable to complete. LPA was also unable to review medication and will return at a later date to complete annual inspection.

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: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/13/2024 03:00 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: 08/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2024
Section Cited
CCR
87705(f)(1)

1
2
3
4
5
6
7
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(1).
8
9
10
11
12
13
14
 *** Based on LPA's & Interim Admin.'s observation the facility did not maintain items that can constitute a danger, inaccessible to residents. During toured of facility at 9:30 AM it was observed unlocked sharps in residents rooms, scissors, razors, hydrogen peroxide, and other hygen products. (Photos taken) which poses an immediate health, Safety risk to residents in care.
8
9
10
11
12
13
14
 Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 8/14/2024, and Training to be submitted by due date of 8/23/2024.
Type B
08/23/2024
Section Cited
CCR87303(a)

1
2
3
4
5
6
7
87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement was not met by licensee as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator to submit plan of repairing the electrical & air control issue in rm23, and plan on repairs to the kitchen pantry ceiling & gas stove, room 20's window screen. Submit plans of corrections, and estimated start and completion dates. POC due 8/19/24
8
9
10
11
12
13
14
Based on LPA & interim Admin's observation resident rm 23 had no electrical lighting in room & bathroom for over a week along with air temp control unit has been inoperable for weeks. resident's entire room moved during LPA visit. rm 20 does not have a screen on window, & kitchen pantry has large hole (see pics) cut by staff due to leak in air conditioning system& pilot light on kitchen stove is falty (blowing out w/air movement) needs to be replaced (could cause gas leak). Which poses a potential health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
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: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2