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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803698
Report Date: 12/06/2022
Date Signed: 12/06/2022 03:21:50 PM

Document Has Been Signed on 12/06/2022 03:21 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VINEYARD AT FOUNTAINGROVE, THEFACILITY NUMBER:
496803698
ADMINISTRATOR:DARIEN GOSTASFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 64CENSUS: 43DATE:
12/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Darien GostasTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA), Shannan Hansen arrived unannounced at facility for the purpose of conducting a Case Management-Deficiency inspection. LPA Hansen met with Administrator, Darien Gostas, toured the facility, conducted interviews, and obtained documents.

Community Care Licensing (CCL) received a Special Incident Report (SIR) that on 11/25/2022 resident (R1) left the facility unassisted at 2:01 PM and was found by a neighbor who contacted Local Law Enforcement who then returned R1 at 02:55 PM. Resident physician's report dated for 1/11/2021 states that resident has a diagnosis of dementia and not allowed to leave facility unassisted. While at facility conducting case management LPA was informed by Administrator R1 eloped leaving the facility through the same exit unassisted a second time on 12/5/222 at 12:48 PM. Facility was contacted by Local Law Enforcement of R1’s ware bouts at which facility picked up and returned resident. On 12/5/22 R1 had medication change to decrease wandering/exit seeking behavior(see copies, LIC 809-D).

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided to the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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Document Has Been Signed on 12/06/2022 03:21 PM - It Cannot Be Edited


Created By: Shannan Hansen On 12/06/2022 at 02:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2022
Section Cited
CCR
87705(b)(2)

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87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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Facility to assess each delayed egress/exit and to ensure they are functioning properly. Facility to conduct in-service staff training regarding elopement and have facility elopement policies and procedures reviewed and in place.
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Based on interview, SIR’s, and Physician’s report, R1 eloped w/out staff knowledge on 11/25/2022 & 12/5/2022 and was contacted by Law Enforcement to R1's ware abouts, the facility didn’t comply w/section above to address behaviors such as wondering for R1 which poses an immediate Health, Safety risk to residents in care.
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 Admin to submit acknowledgement regulation/policies/procedures have been reviewed with staff POC due date 12/7/22. Admin to submit staff in service training regarding elopement sign in sheet with dates submitted to CCL by 12/14/22.

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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 Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
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