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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
496803698
Report Date:
12/31/2024
Date Signed:
12/31/2024 11:24:23 AM
Document Has Been Signed on
12/31/2024 11:24 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, THE
FACILITY NUMBER:
496803698
ADMINISTRATOR/
DIRECTOR:
SANDHU,RAJVIR
FACILITY TYPE:
740
ADDRESS:
200 FOUNTAINGROVE PKWY
TELEPHONE:
(707) 544-4909
CITY:
SANTA ROSA
STATE:
CA
ZIP CODE:
95403
CAPACITY:
64
CENSUS:
28
DATE:
12/31/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:
Serina Barredo
TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst Leibert returns today for a proof of correction visit regarding a deficiency that was cited on 10/08/2024 regarding electrical problems in four residents' rooms. LPA toured the facility and noted that the electrical problems have been resolved and the deficiency is cleared.
Report left.
SUPERVISORS NAME
:
Carla Martinez
LICENSING EVALUATOR NAME
:
David Leibert
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/31/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
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