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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 09/16/2021
Date Signed: 09/16/2021 01:50:34 PM

Substantiated


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
06/16/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210616085247
FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:UBALLEZ, DAVIDFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:58CENSUS: 19DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:David UballezTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff are not trained
Medication is not being stored inaccessible to residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with Administrator Uballez and discussed the findings. This investigation has included a review of records; statements from staff, residents. and witnesses, as well as four site visits. The following determinations are made: Staff (S3) and two co-workers of S3 state that S3 occasionally covers for caregivers on break for short periods of time on the Memory Care floor; Administrator denies S3 covers for caregivers; S3 does not have the required training to provide caregiving; S4 and S5 state that S5 was directed by Administrator to pass medication on 6/14/2021; Administrator does not recall asking S5 to pass meds; S5 has not had all medication training required by CA H&S 1569.69; On 09/02/2021, LPA observed prescription eye drops in unlocked bedroom on assisted living floor. Based upon observations, statements, and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED. ***Continued page 2***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
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 4
Control Number 21-AS-20210616085247
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: VINE RIDGE AT CLOVERDALE
FACILITY NUMBER: 496803825
VISIT DATE: 09/16/2021
NARRATIVE
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The following deficiencies were observed (see LIC 9099D) 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.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20210616085247
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: VINE RIDGE AT CLOVERDALE
FACILITY NUMBER: 496803825
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2021
Section Cited
CCR
87465(h)(2)
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87465(h)(2) Incidental Medical and dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. ***Based upon observation, this requirement has not been met
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Administrator shall provide refresher training to all staff on the topics covered under 87465 and will provide proof of training by POC date in order to clear the deficiency.

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as evidenced by: LPA observed prescription eye drops in unlocked resident’s room on September 02, 2021. This posed an immediate risk to health and safety of residents in care.
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Type A
09/20/2021
Section Cited
CCR
87405(h)(4)
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87405(h)(4) Administrator – Qualifications and Duties. The administrator shall have the responsibility to: ….(4) Recruit, employ and train qualified staff, and terminate employment of staff who perform in an unsatisfactory manner. ***Based upon statements and records review, this requirement has not been met as

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Administrator will prepare, sign and date a declaration stating that all staff will be trained, as required, prior to any caregiving duties. Administrator will submit proof of training for any staff dispensing medications or providing care giving who have not been trained per requirements of Title Twenty-Two regulations. Declaration

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evidenced by: S3 and S5 have provided care to residents without all required training. This posed an immediate risk to the residents in care.
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and proposed training due by POC date to with follow-up training verification to follow.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
06/16/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210616085247

FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:UBALLEZ, DAVIDFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:58CENSUS: 19DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:David UballezTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Centrally Stored Log is not being maintained
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with Administrator Uballez and discussed the findings. This investigation has included a review of records; statements from staff, residents. and witnesses, as well as four site visits. The following determinations are made: It has been alleged that the Administrator has not logged in medication into the Centrally Stored Medication Log when medications are received for residents in care. Staff from CCL has monitored the CSM log during the course of several site visits and have found that the log is being maintained with the required information. A review of prior logs indicate the are maintained according to regulation. Although the allegation may be true, or is valid, there is not a preponderance of evidence to prove the allegation did or, did not, occur. Therefore, the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4