496803698-8-21-2024-21-AS-BMOS-D8SRVA-20240904132113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 08/21/2024
Date Signed: 08/21/2024 03:11:43 PM

Unsubstantiated

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
07/03/2024 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20240703140453

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: 38	DATE:	08/21/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Nancy Steers-Crist Interim Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide resident with water for an extended period of time

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced at facility to deliver complaint findings. LPA met with Interim Administrator Nancy Steers-Crist.

Staff did not provide resident with water for an extended period of time – Complainant alleges on June 27th, resident (R1) was sitting outside in the courtyard for 4-6hrs and facility staff did not offer any water to R1 during the time the resident was seated outside. During complaint investigation LPA conducted 4 unannounced visits to the facility (7/7-7/16-7/30-8/15/2024). On each of the visit’s LPA observed a large water dispenser and a pitcher of juice at both kitchenettes (east & west) and additional pitchers of water and juice in both kitchenette refrigerators (see pictures). LPA was informed facility’s hydration protocol for residents is: There are two water stations on each side (east & west) of the facility and caregivers give out and check on hydration of residents every hour to 2 hours (so if they decline water on the first hour, response caregivers check those residents again at the second).
Continue on LI9099-C

Unsubstantiated

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: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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 2

Control Number 21-AS-20240703140453

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: 08/21/2024

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
26
27
28
29
30
31
32

Continue from LI9099-

The facility has two water containers on patio tables under the umbrella that have ice also in it for the residents that sit out in the courtyard. This is so the care team can walk out and get one of the cups next to the water station and offer water to the residents. The facility also offers Jello & Popsicles & ice cream, not only for break but if residents want something extra. This occurs daily. LPA’s interview with outside party revealed R1 likes being outside in the sun and on 6/27/2024 R1 did not want to come in, after many different attempts with different faces to get R1 to come in, one staff was out there, staff (S1) and was not getting any results and R1 was pulling against S1 who had their arm, so outside party directed S2 to take over. Outside party left then. LPA’s interview with S2 corroborated with outside party that R1 did receive multiple opportunities for hydration breaks and intake of fluids was observed by S2. In addition, LPA obtained Law Enforcement investigation report that concluded there is no evidence to support the allegation and therefore is unfounded. During investigation LPA conducted 4 unannounced visits, making observations, conducted interviews, and obtained Police Report findings that conclude allegation of Staff did not provide resident with water for an extended period of time is found to be Unsubstantiated.

A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2