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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 01/17/2023
Date Signed: 01/17/2023 03:12:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2023 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20230113121330
FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:SMITH, ANGIEFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:58CENSUS: 23DATE:
01/17/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Angie SmithTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Facility is not following Covid protocols
INVESTIGATION FINDINGS:
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a complaint investigation regarding the above complaint allegation and met with Administrator, Angie Smith.

During visit LPA made observations, reviewed documents and conducted interviews.

Facility is not following Covid protocols - Complaint alleges that facility staff are not wearing masks while in the facility. During this visit, LPA observed two of seven staff who did not have a mask on. LPA discussed observations with the Administrator who stated they would discuss with staff to ensure they are wearing masks.

The allegation that facility is not following Covid protocols is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2023 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20230113121330

FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:SMITH, ANGIEFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:58CENSUS: 23DATE:
01/17/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Angie SmithTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Facility staff are not following resident's care plan
Reporting Requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a complaint investigation regarding the above complaint allegation and met with Administrator, Angie Smith.

During visit LPA made observations, reviewed documents and conducted interviews.

Facility staff are not following resident's care plan - Complaint alleges that resident, R1 is not assisted with their bedtime routine which includes staff putting resident in their bed to sleep. Complaint alleges that R1 recently eloped because they were left downstairs in a common area of the facility and not brought to their room at bedtime adding that staff left at 10:00pm. Per discussion with staff, R1 frequently requests to watch television in the common area until late resulting in the overnight (NOC) staff assisting the resident to bed instead of the night (PM) shift whose shift is over at 10:00pm. Due to the recent incident, Administrator has instructed the staff on PM shift to assist resident with their bedtime routine instead so resident is not in the common area late at night.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20230113121330
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VINE RIDGE AT CLOVERDALE
FACILITY NUMBER: 496803825
VISIT DATE: 01/17/2023
NARRATIVE
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Continued from LIC9099A

Reporting Requirements - Complaint alleges that facility did not report the recent Covid outbreak or the elopement of resident, R1. Administrator provided LPA a fax that was sent in November 2022 for an incident with a resident. On the cover sheet of the fax the Administrator indicated that there was also Covid in the building. While LPA confirmed receipt of the incident report, the cover sheet was not seen by LPA when incident report was received. LPA has discussed with Administrator that while technically they notified the Department, the information provided was not sufficient. LPA clarified with Administrator what was needed when reporting and Administrator indicated they understood. Per conversation with Administrator regarding the alleged elopement, Administrator stated that they did not report it because it was their understanding that the resident was found on the property. LPA indicated to Administrator that per review of the police report, the resident was found on the sidewalk so was not on the property. Review of resident's Physician's Report indicates that resident is able to leave the facility unassisted.

A finding that the complaint allegations that Facility staff are not following resident's care plan and Reporting Requirements was unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegations occurred.

No deficiencies cited.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2023 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20230113121330

FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:SMITH, ANGIEFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:58CENSUS: 23DATE:
01/17/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Angie SmithTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Neglect/Lack of Supervision resulting in resident eloping the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a complaint investigation regarding the above complaint allegation and met with Administrator, Angie Smith.

During visit LPA made observations, reviewed documents and conducted interviews.
Neglect/Lack of Supervision resulting in resident eloping the facility - Complaint alleges that resident, R1 was left in a common, downstairs area of the facility when they became confused and left the facility late on 1/4/2023. Per complainant, the resident was found by a passerby who contacted the police. Police returned resident to the facility. Review of the police report indicates that R1 was found on the sidewalk outside of the facility around 11:30pm on 1/4/2023. Review of resident's file indicates that the facility requested an updated Physician's Report on 1/3/2023. R1's doctor provided an updated report dated 1/4/2023 that indicates that R1 is able to leave the facility unassisted.
This agency has investigated the complaint alleging Neglect/Lack of Supervision resulting in resident eloping the facility. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
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 5
Control Number 21-AS-20230113121330
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINE RIDGE AT CLOVERDALE
FACILITY NUMBER: 496803825
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful & comfortable accommodations, furnishings and equipment. This requirement hasn't been met based on LPA observation that 2 of 7 staff did not have a mask on while
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Administrator agrees to conduct an in-service training with all facility staff to ensure they understand that face coverings continue to be required in a licensed facility for all staff and visitors. Proof of in-service to includes date of training, duration and signature of attendees to be submitted to CCL no later than POC due date, 1/23/2023.
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in common areas of the facility, in violation of official government orders requiring the wearing of face coverings while working under specified conditions. This is a potential risk to health & safety of residents.
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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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5