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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 10/13/2021
Date Signed: 10/14/2021 11:24:25 AM

Unsubstantiated


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
06/28/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210628121743
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: 21DATE:
10/13/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:David UballezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Insufficient care and supervision resulting in an injury
Facility staff did not seek medical attention in a timely manner
Facility staff did not address a change in the resident's condition
Facility is not meeting resident care needs
Personal Rights
Facility staff are not reporting incidents as required
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 and discussed the department's findings. During the course of this investigation statements were taken from staff; residents; witnesses. In addition, six unannounced site visited were made to the facility and photographs were taken of various areas. Numerous records and documents were obtained and reviewed. Complainant alleges that staff are not providing sufficient care and supervision which has resulted in injury, delays in medical treatment, failure to address changes in resident's condition and residents remaining in soiled briefs. It is further alleged that staff violate residents rights by yelling and/or rude remarks directed at agitated residents and that incidents are not reported as required. Based upon this investigation, the following determinations are made: Records for those residents which could be identified indicate appropriate response from staff regarding injury, follow-up care, and reporting of incidents; Family witnesses have expressed confidence in the care given to residents and do not substantiate the allegations; Site visits to the facility found memory care residents dressed appropriately, appearing clean and fresh and engaging with staff without agitation or unusual behaviors. CONTINUED...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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-20210628121743
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: 10/13/2021
NARRATIVE
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Staff and resident interactions were observed during site visits with no inappropriate staff behaviors noted. Staff and family witnesses interviewed report staff interactions with residents to be professional and kind. No evidence was found in review of logs that would suggest failure to report incidents or negative interactions between staff and residents in their care. Although the allegations may be true, or valid, the preponderance of evidence standard has not been met. Therefore, based upon the statements and records reviewed, the allegations are UNSUBSTANTIATED.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 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
06/28/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210628121743

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: 21DATE:
10/13/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:David UballezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility did not make hazardous products inaccessible to residents
Facility staff are not trained
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 and discussed the department's findings. During the course of this investigation statements were taken from staff; residents; witnesses. In addition, six unannounced site visited were made to the facility and photographs were taken of various areas. Numerous records and documents were obtained and reviewed. The following determinations are made: The issue of lack of staff training for the same period has been addressed in Complaint # 21-AS-202106160-85247 received 06/16/2021. During site visit conducted on 08/26/2021, LPA observed laundry spotter products in open resident laundry room. One can full and one ½ full, both with warning labels. A can of Ajax cleanser was found in bathroom not commonly used by residents but accessible to residents. Based upon records reviewed, statements made, and LPA observations, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED. 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.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20210628121743
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: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited
CCR
87309(a)
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87309(a) STORAGE SPACE. Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. ***Based upon observation, this requirement has not been met as evidenced by: Laundry products and

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Administrator will conduct additional training for all staff on topics covered by 87309. Proof of training to be submitted to CCL by POC date in order to clear the deficiency.
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cleanser observed accessible to residents. This posed an immediate risk to the health of residents in care.
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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.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4