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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 07/23/2021
Date Signed: 07/23/2021 01:56:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:VINEYARD AT FOUNTAINGROVE, THEFACILITY NUMBER:
496803698
ADMINISTRATOR:MOONEY, SHAWNFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 51DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Shawn Mooney-AdministratorTIME COMPLETED:
01:40 PM
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Licensing Program Analysts (LPAs) Alviso and Lopez conducted an unannounced Required – 1 yr inspection; This inspection will focus on the facility's infection control procedures. LPA's conducted inspection 7/23/2021 at approximately 10:05am, and met with Administrator, Shawn Mooney. LPAs conducted a Risk Assessment call with staff prior to the visit.

LPAs arrived at the facility and had their temperatures checked. LPAs answered screening questions in sign-in device. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Hot water was checked at 110.F which is within regulation. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. At the time of the visit some Fire Extinguishers were observed to be serviced and tagged as required, and a few others needed to get serviced and tagged. Administrator made a call to the Santa Rosa Fire Equipment services business, and is getting the remaining fire extinguishers serviced today. There was sufficient amount of supply for both perishable and nonperishable foods as required. Food stored in the kitchen refrigerator was properly stored at the time of the visit. The resident bathrooms observed by LPAs had required grab bars, and non-slip mat/non-slip flooring for the showers.

Facility has submitted a mitigation plan that has been reviewed, 6/25/21. Posters have been placed at entrance, and facility entrance area has a designated area to screen visitors. Facility has thermometers and hand sanitizer designated for visitors and staff. Staff and residents are being monitored daily and results are being documented. Facility has a sufficient supply of personal protective equipment (PPE) stored in an empty office room. Medications are kept secured as required in a locked medication room. Toxins and cleaners are kept secured in locked storage areas. Administrator stated that all staff are required to wear masks when working at the facility. LPAs observed staff wearing masks as required. Facility has conducted staff training on infection control.

No deficiencies cited today.

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
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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