<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803825
Report Date: 10/21/2021
Date Signed: 10/21/2021 12:48:08 PM

Document Has Been Signed on 10/21/2021 12:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:UBALLEZ, DAVIDFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 58CENSUS: 21DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator, David UballezTIME COMPLETED:
01:00 PM
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
Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and met with Administrator, David Uballez. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was asked to sign in and had their temperature checked. Facility also requested to see LPA's Covid-19 vaccination card per visitor guidance outlined in Provider Information Notice 21-40-ASC. LPA conducted a walk-through of the facility which included Assisted Living and Memory Care with the Administrator and observed Covid-19 posters throughout the building that included hand washing signs in restrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed throughout the facility specifically inside of elevators and in common areas and hallways. Per Administrator, they regularly discuss infection control with residents and staff. Residents are encouraged to wear masks when in common areas of the facility and staff are required to wear them while in the facility. Observed staff had masks on during this visit.

LPA and Administrator discussed resident activities and visitation. Facility has an Activities Director five days per week who plans a facilitates resident activities. Visitors usually visit in resident's rooms but the facility also has designated visitation areas outside, weather permitting.

Caregivers have completed PPE training but have not been N-95 Fit tested. Administrator is researching how to obtain fit testing to comply with CalOsha standards. Commonly touched surfaces are disinfected at least once per shift. Dining room table and chairs are disinfected before and after meals.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/21/2021
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 LIC809

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is located in both medication rooms and is accessible to staff who need it. Facility maintains a 30 day supply of medication.

Facility continues to test staff per CCL guidance. LPA confirmed that Administrator has reviewed the most recent Provider Information Notices.

Administrator and LPA discussed their Emergency Disaster Plan.



No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2