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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 12/09/2024
Date Signed: 12/09/2024 02:55:00 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
07/22/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240722094535
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: 29DATE:
12/09/2024
UNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Serina Barreda (Business Office Manager)TIME COMPLETED:
03:05 PM
ALLEGATION(S):
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-Staff are transporting clients in an unsafe manner.
-Staff are mismanaging resident medication.
-Staff do not have adequate training.
-Facility telephone is not maintained in working order.
-Facility is in disrepair.
-Staff do not maintain a comfortable temperature for residents at all times.
-Staff do not ensure that residents are fed nutritous meals in the quantity or of the quality required to meet resident needs.
-Staff do not have sufficient supplies to meet the needs of residents in care.
-Staff are not keeping the facility clean and sanitary.
-Staff are not following reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra and support staff Ethel Contreras arrived unannounced for the purpose of delivering findings on this complaint and met with Serina Barreda, Business Office Manager. Complainant alleges multiple allegations that are noted above and referenced below in detail. The complainant is anonymous, and no contact information was provided to obtain additional details on the alleged allegations.

Staff are transporting clients in an unsafe manner- Complainant alleges that the facility van is operated by staff without the proper issued driver license, facility is in despair and routine maintenance is not preformed. During the course of the investigation LPA obtained records to ensure vehicle maintenance and operation meets regulation. LPA obtained records of vehicle maintenance, transporting logbook, current registration and insurance and staff that operates vehicle CA driver’s license. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
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 5
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
07/22/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240722094535

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: 29DATE:
12/09/2024
UNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Serina Barreda (Business Office Manager)TIME COMPLETED:
03:05 PM
ALLEGATION(S):
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-Facility is in financial distress.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra and support staff Ethel Contreras arrived unannounced for the purpose of delivering findings on this complaint and met with Serina Barreda, Business Office Manager.
Facility is in financial distress- Complainant alleges the facility is in financial distress due to facility bills not being paid and an interruption of services. The Department conducted a previous investigation and substanited the same allegation due information obtained during interviews and the facilities failure to comply with the Departments solvency audit, a citation was issued. See complaint 21-AS- 20230803084501. An office meeting was held on 4/15/2024 and the facility was placed on a 2-year non-compliance plan agreeing to comply with the Departments review. The Department engaged the facilty to conduct a subsequent solvency audit which concluded with the conclusion of; Based on documentation and information received and reviewed, the licensee had negative income, fell behind on some utility bills, with 12 utility bills totaling $64,983 in past due bills, $1,301 in late fees incurred, and received a disconnection notice from City of Santa Rosa for water service. It appears the licensee does not have an adequate financial plan required by Section 87213 Finances to ensure sufficient income/resources generated to cover the facility’s operating expenses to ensure adequate care and supervision for residents. Based on the result of the solvency audit outcome the Department will engage the facility in continued financial monitoring and the allegation of the facilty is in financial; distress is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20240722094535
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2024
Section Cited
CCR
87213
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87213 Finances - The licensee shall have a financial plan that conforms to the requirements of Section 87155... & that assures sufficient resources to meet operating costs for care of residents... This requirement had not been met as evidence by:
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The facility business manager agrees to work with Licensee to comply with the Departments continued financial monitoring. The facility will submit a written statement by 12/10/24.
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Based on the documentation and information received and reviewed, the licensee does not have an adequate financial plan to cover the facility’s operating expenses, to provide adequate care and supervision for residents, which is an immediate risk to health & safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20240722094535
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: 12/09/2024
NARRATIVE
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Continue from LIC9099...
Staff are mismanaging resident medication-Complainant alleges that facilty has not properly disposed of narcotics and expired medication. A co-complainant was added for this allegation 11/5/2024 and the Department was unable to reach this individual for additional information. Expired medication can be found in box in health and wellness office and stuffed in drawers. During the course of the investigation LPA made observations in the facility on 7/30/2024, 8/13/2024, 8/15/2024, 8/21/2024 and 9/10/2024 and did not observe expired medication or narcotics pending destruction. LPA reviewed and obtained medication destruction logs which appear to be complete and indicated two signatures. LPA conducted interviews with health and wellness director who showed good understanding of facility policy and regulation pertaining to medication storage and destruction of medication. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Staff do not have adequate training- Complainant alleges that facility is not in compliance with training requirements, referring to new hire/onboarding and shadowing requirements. LPA obtained a sample of (4) new hire training records and logs. Based on review of training records and interviews conducted facility appears to be in compliance with regulation pertaining to staff training. Annual inspection was conducted on 8/21/2024 and a citation was issued for annual dementia training, but this training requirement was not part of the complaint’s allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Facility telephone is not maintained in working order- Complainant alleges non-payment of invoices has resulted in phone service disruption for a full week. Complainant did not indicate what week was in reference and LPA is unable to contact for additional information. The Department conducted an inspection pertaining to the same allegation in complaint 21-AS-20240521215956 and delivered substantiated findings on 6/4/2024. During the course of this current complaint investigation LPA conducted (6) phone calls to the facility between the dates on 7/23/2-024 and 8/7/2024 that included between the hours on 9am to 4:45pm and all calls were answered by facility staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Continued on LIC9099C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20240722094535
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: 12/09/2024
NARRATIVE
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Continued from LIC9099C...Facility is in disrepair & Staff are not keeping the facility clean and sanitary- Complaint alleges that facilty lights are out in hall wall, common restrooms, activity area and resident rooms are not kept clean and sanitary. During the course of the investigation LPA made observations in the facility on 7/30/2024, 8/13/2024, 8/15/2024, 8/21/2024 and 9/10/2024 and did not observe the noted areas in the facility that are not kept clean and sanitary. LPA conducted interviews, obtained photos and made observation in multiple (5) resident’s rooms. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Staff do not maintain a comfortable temperature for residents at all times- Complainant alleges that resident activity room is freezing leaving residnets cold and uncomfortable. It is also noted that medication room does not have a cooling unit. During the course of the investigation LPA made observations in the facility on 7/30/2024, 8/13/2024, 8/15/2024, 8/21/2024 and 9/10/2024 and observed the facility to be in compliance with regulation. The facility is not required to have a cooling unit although must remain in compliance with regulation temperature. LPA conducted interviews with staff and did not obtain information to support this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Staff do not ensure that residents are fed nutritious meals in the quantity or of the quality- During the course of the investigation LPA made observations in the facility on 7/30/2024, 8/13/2024, 8/15/2024, 8/21/2024 and 9/10/2024 and perishable and non-perishable foods appeared to be in compliance with regulation. LPA obtained photos of food supply and meals being prepared and offered to residents. LPA conducted interviews with staff and was unable to obtain information to support this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Staff do not have sufficient supplies to meet the needs of residents in care- LPA made observations in the facility on 7/30/2024, 8/13/2024, 8/15/2024, 8/21/2024 and 9/10/2024 and observed a sufficient supply on supplies to meet the needs of residents in care. LPA obtained photos of care products in multiple locations in the facility. LPA conducted interviews with staff and was unable to obtain information to support this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Staff are not following reporting requirements- During the course of the investigation and review of self-reported incident reports LPA was unable to identify an event that the facility failed to follow reporting requirements. LPA is unable to contact the complainant to obtain additional information into an incident that facilty failed to report to licensing. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5