496803825-9-10-2024-21-AS-BMOS-D96MTR-20240916095355

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:18:21 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/10/2024 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240710150350

FACILITY NAME:	VINE RIDGE SENIOR LIVING		FACILITY NUMBER:	496803825
ADMINISTRATOR:	SMITH, ANGIE		FACILITY TYPE:	740
ADDRESS:	247 TREADWAY DRIVE		TELEPHONE:	(707) 791-4787
CITY:	CLOVERDALE	STATE: CA	ZIP CODE:	95425
CAPACITY:	99	CENSUS: 24	DATE:	09/10/2024
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Carla Lua (acting Administrator)		TIME COMPLETED:	02:33 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Resident sustained an injury while in care.
-Staff do not ensure adequate care and supervision is provided to residents.
-Staff leave residents in soiled clothing for extended periods of time.
-Staff do not ensure a safe environment is provided for clients in care.
-Staff do not ensure safe transfer methods are used for residents in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with acting Administrator, Carla Lua.

Resident sustained an injury while in care. Per Reporting party, staff would leave spills on the floor, causing residents to slip and fall in the facility. The Reporting party stated that three weeks ago a resident (R1) had a bad fall in the bathroom due to one of the staff leaving them in the bathroom alone. R1 lost their balance and hit their head. The Reporting party acknowledged that medical treatment was provided immediately, and the resident was taken to the emergency room. Based on records review, on 6/24/24 the facility submitted an incident report notifying to the Department that on 6/20/24 at approximate 2pm, R1 had an unwitnessed fall and injury. Per incident report, staff found R1 on the restroom floor, they have notified 911 immediately and R1’s responsible party, R1 was transported to the hospital for further evaluation.
Continue on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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-20240710150350

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINE RIDGE SENIOR LIVING	FACILITY NUMBER: 496803825
	VISIT DATE: 09/10/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099...
Discharge documents for R1 confirmed that R1 was discharged the same day with a diagnosis of facial laceration and closed head injury. R1’s care plan dated 6/23/23 indicates that due to their memory challenges, it was determined that staff will escort resident to the bathroom, give verbal prompts/cues with toileting tasks. However, R1’s physician report dated 9/25/23 revealed that R1 is capable for self-care including toileting needs. Although R1 had a fall, the investigation did not reveal information that injury while in care was due to any lack of supervision. A finding that the complaint allegation of resident sustained an injury while in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Staff do not ensure adequate care and supervision is provided to residents. The Reporting party stated that they noticed residents in the memory care unit with bumps on their heads that weren't there before due to staff do not check on residents as often as they should do, the staff are supposed to be checking on residents every two hours to repositioning or taking them to the bathrooms, but they are just logging into the paperwork that they did, but it is not happening. During LPA’s interviews with reporting party, LPA requested names of staff or residents, but complainant could not provide any further details. Based on records review of facility records, staff are assigned tasks that are documented into the assignment sheet/ADL’s checklist/NOC memory care round checks sheet. Upon reviewing facility logs as follow: assignment sheet for the month of August 2024 indicates at least two staff need to be present in memory care unit to assist residents in care. ADL’s checklist for the month of August 2024 indicates that staff have ensured that each resident’s care plan and needs are being met daily. NOC memory care round check sheet information details continence status as well as how each resident was found including on recliner, sleeping, etc. during checks performed at 10pm, 12 am, 2am, 4am and 6am respectively. Staff schedule and staff timesheet for the month of August 2024 confirmed that there is an average of two caregivers, med-technician/aide per morning and afternoon shift, two caregivers at night shift to provide care and supervision for nine residents in memory care unit.

Continue on LIC9099C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20240710150350

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINE RIDGE SENIOR LIVING	FACILITY NUMBER: 496803825
	VISIT DATE: 09/10/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099C...

Also, physician’s report and care plans of residents (R1, R2, R3, R4, R5, R6, R7 & R8) in the memory care unit indicates that they are not required to have two-person assist to help them to meet their needs. A finding that the complaint allegation facility staff did not ensure adequate care and supervision is provided to residents is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Staff leave residents in soiled clothing for extended periods of time. Per Reporting party, staff would neglect residents incontinent care needs. The Reporting party stated that several staff would just leave residents in their soiled clothing for extended periods of time and not taking them to the restroom. Based on records review, the facility has an assignment shift where staff are documenting rounds and times of task performed. According to facility records, staff are assisting residents timely with their continence needs every two hours or as needed. Based on interviews conducted by LPA with facility staff (S1, S2, S3, S4, S5 & S6) acting administrator or resident care coordinator will communicate with them regarding any changes of condition of any resident. Supplies of incontinence care are provided by the facility, unless that resident have any special preference/needs of supplies, they will be brought by hospice or their responsible parties. However, during the investigation there was no information or supporting evidence that could indicate that any of the incidents above mentioned have happened at a prior date. A finding that the complaint allegation of staff leave residents in soiled clothing for extended periods of time is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Staff do not ensure a safe environment is provided for clients in care. The Reporting party have noticed that memory care residents would often leave their recliners open and then trip and fall on them, because many staff would not check on residents to make sure the recliners were closed. During LPA’s interviews conducted with the reporting party, they have explained to LPA that they were referring to the strong smell of urine that could be perceived in the morning when anybody enters the memory care unit area. Continue on LIC9099C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 21-AS-20240710150350

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINE RIDGE SENIOR LIVING	FACILITY NUMBER: 496803825
	VISIT DATE: 09/10/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099C...

On 8/9/24 LPA toured the memory care unit and observed that there were recliners available in the common area/dining room. Based on interviews conducted by LPA with staff (S1, S2, S3, S4, S5 & S6) and residents (R1, R2 & R3) indicates that staff helps them to use the recliners, they revealed that at times there are recliners located in the common area that had been found open, but they close them to prevent a further fall hazard issue. Also, staff indicates that they have observed other co-workers to closed them as well as a safety measure. but there no concerns raised that could indicate that they are left open causing an unsafe environment for residents in care. LPA toured the memory care unit and observed closed recliners in a couple of resident’s rooms. A finding that the complaint allegation of staff does not ensure a safe environment is provided for clients in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Staff do not ensure safe transfer methods are used for residents in care. Per Reporting party, it has been observed staff would practice unsafe transfers with the residents by not using the belt assist device. On 8/9/24, LPA conducted interviews with staff (S1, S2, S3, S4, S5 & S6) to have them explain the current protocol of transferring residents from their wheelchairs to their bed. Interviews with staff indicated that they do have a protocol in place where they will assess if resident is one or two people assist, they will call another staff (if needed), place wheelchairs close to resident’s beds, they will put the brakes on to ensure safety of the transfer, then they will lift slowly the resident, but not aggressively, some of them will stand up a little bit, and get them transferred to their bed. After finishing their transfer, they will put the wheelchair aside where they won’t represent a hazard trip issue. Based on records review of staff training on file, they are following training protocols regarding transfer of residents from their wheelchairs to their beds. A finding that the complaint allegation of staff does not ensure safe transfer methods are used for residents in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during today's visit. Exit interview conducted with acting administrator and a copy of this report was given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4