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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:52:50 PM


Document Has Been Signed on 09/10/2024 12:52 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: 36DATE:
09/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Cheyenne Flores, Health Services DirectorTIME COMPLETED:
01:00 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
At approximately 12:05PM, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management - Other visit and met with the Manager on Duty Cheyenne Flores, Health Services Director as Administrator was unavailable. The purpose of today's visit is to conduct a Non-Compliance (NCC) inspection.

LPA requested and reviewed documents for all employees hired from April 2024 to September 2024. Review of documents showed that facility hired 30 individuals during this time frame and has either conducted training or have scheduled training for them in the following areas: Medication, care giving for dementia residents, Medication shadowing.

· Financial Solvency – Auditing Dept handling
· Fire clearance concerns (Fire Department involvement) - POC has been cleared
· Insufficient care and supervision & medication errors as previous multiple citations – (facility is currently under investigation)
· Administer duties/qualifications
· Licensing fees (late fees not paid 2nd notice sent) –LPA informed of outstanding and overdue Licensing fees.
· Facilities future compliance
During visit, LPA was informed that Executive Director, Rajvir Sandhu, will be overseeing the community as the new Administrator. LPA requested Administrator documents to be submitted to Community Care Licensing (CCL) by 09/23/2024.
No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
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 1