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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803825
Report Date: 09/09/2022
Date Signed: 09/09/2022 03:45:28 PM

Document Has Been Signed on 09/09/2022 03:45 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:LANHAM, RACHAELFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 58CENSUS: 26DATE:
09/09/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Administrator, Angie SmithTIME COMPLETED:
03:55 PM
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Licensing Program Analyst Willis arrived unannounced to conduct a Plan of Correction visit and to amend a report and met with Administrator, Angie Smith.

On August 31, 2022 facility was cited for violating regulation 87411(a) Personnel Requirements - General and 87464(f)(4) - Basic Services. Licensee has submitted a correction to 87411(a). The correction for deficiency 87464(f)(4) states that "Licensee agrees to submit an updated policy outlining how all staff including but not limited to kitchen staff, caregivers, Medication Technicians and Activity Directors will be notified of resident's needs and how facility will ensure the needs are met." Licensee has written a letter indicating that they will not be changing their policies or protocol. Because a correction to the deficiency is required, LPA discussed the concern with the Administrator. Based on LPA's observation today and conversation with Administrator LPA will clear deficiency 87464(f)(4) and Administrator agrees to submit an updated LIC500.

On the LIC809D form dated August 31, 2022 LPA put an incorrect code under the Section Number so has returned to correct that error.

Facility has a new Administrator and LPA has notified them of the requirement that documents to change the Administrator of record must be sent to CCL within 30 days.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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