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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 10/25/2024
Date Signed: 10/25/2024 11:13:03 AM


Document Has Been Signed on 10/25/2024 11:13 AM - 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: 34DATE:
10/25/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rajvir SandhuTIME COMPLETED:
11:30 AM
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
Licensing Program Analyst Leibert arrived unannounced for a Plan of Correction visit and met with the Administrator. A case management inspection was conducted on 10/08/2024 regarding electrical problems in 4 resident apartments. Correction/repairs were to be completed by 10/22/2024. At today's visit, LPA learned that the repairs had not been made and that the facility's Home Office had just approved the hiring of an electrician to deal with the issues.

A civil penalty is the amount of $300.00 is issued today for the period of 10/23 thru 10/25 at the rate of $100.00 per day. Additional civil penalties are assessed at the rate of $100.00 a day until the deficiency is corrected.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024
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