496803825-9-30-2022-21-AS-VBEI-CJRSK4-20220930135605

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803825
Report Date: 09/30/2022
Date Signed: 09/30/2022 01:56:24 PM

Document Has Been Signed on 09/30/2022 01:56 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	VINE RIDGE AT CLOVERDALE		FACILITY NUMBER:	496803825
ADMINISTRATOR:	LANHAM, RACHAEL		FACILITY TYPE:	740
ADDRESS:	247 TREADWAY DRIVE		TELEPHONE:	(707) 791-4787
CITY:	CLOVERDALE	STATE: CA	ZIP CODE:	95425
CAPACITY: 58		CENSUS: 26	DATE:	09/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Anie Smith		TIME COMPLETED:	02:05 PM

NARRATIVE

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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Administrator, Angie Smith. Licensee, Larona Farnum arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

LPA arrived at approximately 9:00am and observed the following. LPA was asked to sign in. A notice at the reception desk indicated that visitors would no longer be screened per new guidance. LPA clarified that the new guidance no longer requires staff to verify vaccinations for visitors, but they must still be screened per Provider Information Notice (PIN) 22-28-ASC. Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per dayimes per day. Facility maintains documentation of staff and resident daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Facility has included training on infection control and proper usage of Personal Protective Equipment to their annual training.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced February 2021. Smoke and carbon monoxide detectors are monitored and serviced through a vendor.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/30/2022

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Continued from LIC809C

Licensee and LPA discussed the recent elopement of resident, R1 from the Memory Care unit. Per review of R1's physician's report, R1 is not able to leave the facility unassisted and has wandering behavior.

Licensee and LPA discussed their Emergency Disaster Plan and Infection Control Plan. LPA was provided documents for the recent change of administrator.

Licensee/Administrator to submit updates of the following documents by 10/30/2022:

LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (review and update)
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Liability Insurance

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.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/30/2022 01:56 PM - It Cannot Be Edited

Created By: Victoria Bertozzi On 09/30/2022 at 01:26 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(b)(2)

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in one out of one instance of a memory care resident eloping the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/01/2022
	Plan of Correction
1 2 3 4	Facility has assessed each delayed egress/exit to ensure they are functioning properly, increased monitoring and safety checks and resident was put on alert charting. Defiency is cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Hope DeBenedetti

LICENSING EVALUATOR NAME:

Victoria Bertozzi

LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC809 (FAS) - (06/04)

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