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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 12/26/2024
Date Signed: 12/26/2024 02:18:32 PM

Document Has Been Signed on 12/26/2024 02:18 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, THEFACILITY NUMBER:
496803698
ADMINISTRATOR/
DIRECTOR:		SANDHU,RAJVIRFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 64TOTAL ENROLLED CHILDREN: 0CENSUS: 28DATE:
12/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Serina Barreda, Business Office ManagerTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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12/26/2024, Licensing Program Analyst (LPA) Loera arrived at facility to conduct a Case Management to follow up on an elopement.

Per conversation and interview with Serina Barreda it was found Resident (R1) did not elope. R1 was found in another residents closet as they are known to wander and put on other residents clothing. R1 was taking clothing from another residents closet when an item fell from the top and hit them on the head and fell with a blanket over them. R1 was missing on 12/24/2024 around 6:00 - 6:30 pm and facility called SRPD. R1 was found by a caregiver on 10/25/2024 approximately at 10:51 am covered with a blanket on them. R1 was admitted to the hospital 12/25/2024 and is currently still there. Facility will be sending in a SIR to CCL.

LPA gathered documents and interviewed staff.

Further investigation is needed for Follow-Up.

No deficiencies cited during today's visit.
Kimberley MotaTELEPHONE: (707) 588-5071
Anthony LoeraTELEPHONE: (707) 588-5026
DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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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