496803698-11-13-2024-21-AS-CFES-DAYVPG-20241113153645

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 11/13/2024
Date Signed: 11/13/2024 03:37:20 PM

Document Has Been Signed on 11/13/2024 03:37 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	VINEYARD AT FOUNTAINGROVE, THE		FACILITY NUMBER:	496803698
ADMINISTRATOR/ DIRECTOR:	ANTONETTE EDWARDS		FACILITY TYPE:	740
ADDRESS:	200 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 544-4909
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 64	TOTAL ENROLLED CHILDREN: 0	CENSUS: 33	DATE:	11/13/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Business Office Manager, Serina Barerra, Health and Wellness Director, Cheyenne Flores, and Executive Director, Rajvir Sandhu		TIME VISIT/ INSPECTION COMPLETED:	03:50 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 9:20AM, Licensing Program Analysts (LPAs) Felias and Loera arrived unannounced to conduct a Case Management - Other visit, and met with Business Office Manager, Serina Barerra. Health and Wellness Director (HWD), Cheyenne Flores, arrived during visit at approximately 10:45AM and Executive Director (ED), Rajvir Sandhu, arrived at approximately 11AM.

During visit conducted on 11/13/2024, the Department learned that Facility has not been submitting written reports to Community Care Licensing (CCL) per regulation. LPAs requested that all incident and death reports be submitted to the Santa Rosa Regional Office immediately for the following time frame: July 2024 to present date. Per discussion with ED and HWD, LPAs discovered that all written reports were being sent to the wrong fax number. Facility was unable to provide proof of fax confirmations or copies of Licensing incident and/or death reports (LIC624 and LIC624A). LPAs obtained physical hard copies of facility's internal incident reports from July 2024 - present date (deficiency cited, LIC809D, regulation 87211(a)(1)).

LPAs observed that facility was unable to produce the following records within a reasonable time frame due to not having access: Facility's Electronic Medication Authorization Records for discharged residents, and Facility's Centrally Stored Medications/Destruction Log. LPAs were informed by the Business Office Manager that these documents were accessible only by the HWD as they did not have the keys to the Health and Wellness office or the log-in information to the records system. Upon HWD's arrival, LPAs immediately requested for records to be pulled for review (deficiency cited, LIC809D, regulation 87506(d)). LPAs observed that facility has not destroyed narcotic medication timely per their facility protocol. Facility's Medication Disposal Procedures state: "If medications are narcotics, they need to be disposed of...as soon as they are expired or discontinued..." LPAs observed that the following narcotics to not be destroyed timely: Lorazepam and Morphine. These medications had expiration dates of May 2024 and October 2024. LPAs obtained pictures (deficiency cited, LIC809D, regulation 87465(i)).

Continued on LIC809C

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Caitlynn Felias	TELEPHONE: 707-588-5039
	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

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 4

Document Has Been Signed on 11/13/2024 03:37 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
SANTA ROSA RO, 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: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted...within seven days of the occurrence of any of the events specified...below. This requirement was not met as evidenced by: Licensee did
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 11/14/2024
	Plan of Correction
1 2 3 4	Licensee to submit self certification that in-service training will be conducted for all direct care staff by POC due date of 11/14/2024. Inservice Training to include the following: Date, Training Topic, Name/Job Role, and Signatures. Training to be submitted by POC due date of 11/23/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Caitlynn Felias	TELEPHONE: 707-588-5039
	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 11/13/2024 03:37 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
SANTA ROSA RO, 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: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87465 Incidental Medical and Dental Care: (i) Prescription medications...to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years... This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 11/14/2024
	Plan of Correction
1 2 3 4	Licensee to submit self certification that in-service training will be conducted for all direct care staff by POC due date of 11/14/2024. Inservice Training to include the following: Date, Training Topic, Name/Job Role, and Signatures. Training to be submitted by POC due date of 11/23/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Caitlynn Felias	TELEPHONE: 707-588-5039
	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINEYARD AT FOUNTAINGROVE, THE	FACILITY NUMBER: 496803698
	VISIT DATE: 11/13/2024

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

Continued from LIC809

LPAs also followed up on Administrator paperwork for Rajvir Sandhu. The Department is missing Board Minutes to proceed with updating the Facility Administrator/Executive Director. Per Executive Director, they have been contacting their Corporate Organization for the paperwork but have not received any documentation at this time.

Executive Director also informed LPAs that the facility will be undergoing a management change effective December 1, 2024. Facility to email CCL with an update regarding management status. LPAs provided facility with Santa Rosa Regional Office contact information.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (deficiency page) Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4