496803698-9-23-2021-21-AS-HDBI-C7L38Y-20211007180218

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 09/23/2021
Date Signed: 09/23/2021 05:32:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/22/2021 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210622135120

FACILITY NAME:	VINEYARD AT FOUNTAINGROVE, THE		FACILITY NUMBER:	496803698
ADMINISTRATOR:	MOONEY, SHAWN		FACILITY TYPE:	740
ADDRESS:	200 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 544-4909
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	64	CENSUS:	DATE:	09/23/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Shawn Mooney-Administrator		TIME COMPLETED:	03:09 PM

ALLEGATION(S):

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Resident had a fall and sustained multiple injuries due to staff negligence and lack of care
Facility staff are not assisting resident in a timely manner.
Facility staff did not transfer the resident properly
Facility staff did not follow resident care plan

INVESTIGATION FINDINGS:

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Licensing Program Analysts, Dina Alviso and Shannan Hansen, conducted a complaint inspection, and met with Administrator Shawn Mooney. The inspection is being conducted to deliver findings.

The Department interviewed facility staff, S1, S2, S8, S9 and S10, residents, R4, R5, R6, and R7, and interviewed other various parties in relation to . The Department obtained resident (R1) facility records, and also obtained R1's hospital medical records.

The investigation revealed, R1 was a full need resident and required hourly checks. R1 did have changes in their condition, and in their care needs, and these were documented per record review. Facility staff stated they conducted hourly checks on R1, and also conducted routine hygiene/incontinent care on R1 per record review and interviews.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210622135120

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, THE	FACILITY NUMBER: 496803698
	VISIT DATE: 09/23/2021

NARRATIVE

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Per record reviews and interviews, R1 was a two person transfer, and a hoyer lift may be used for transferring the resident from bed to chair or chair to bed. R1 had an Alexa device to contact staff for assistance when needing something and/or was also able to contact call others, including responsible parties, at any and all hours day or night. Responsible parties (RPs) and facility staff agreed to RP's are not to be contacted from 10pm through 6am, RP's contact numbers would be turned off so there would be no calls going out to the RP(s) as they had been receiving numerous calls from R1. Facility staff stated they would check on R1 regularly, every hour, to provide any needed services to the resident. The resident was not on a one to one and/or on a line of sight staffed resident, per record reviews, and interviews with staff, and other various parties. Facility staff, and responsible parties were in agreement on resident's care plan, per review of records and interviews conducted.

On 5/31/2021, R1 had a fall and sustained multiple injuries, per record reviews, and hospital medical records. Facility staff reported that on 5/31/21, they had regularly checked on R1 per care plan, provided care services as needed, and immediately responded to R1's room when they heard a loud noise, R1 had a fall in their room, and staff state resident was last seen in their bed from the last check on the resident. Per interviews and record reviews, The caregiver notified the medical technician that R1 had a fall and needed to be assessed. The Medical Technician responded and assessed R1, and immediately called 911 emergency services. R1 was taken to the ER, and was admitted into the hospital for multiple injuries.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations, Resident had a fall and sustained multiple injuries due to staff negligence and lack of care, Facility staff are not assisting resident in a timely manner,
Facility staff did not transfer the resident properly, Facility staff did not follow resident care plan, are Unsubstantiated. Although the allegation(s) 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(s) are Unsubstantiated.
No citations issued.
No deficiencies cited during today’s visit.
Exit interviews were conducted.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

LIC9099 (FAS) - (06/04)

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