496803825-10-12-2023-21-AS-CCOO-CWJUHK-20231012153603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803825
Report Date: 10/12/2023
Date Signed: 10/12/2023 03:36:20 PM

Document Has Been Signed on 10/12/2023 03:36 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 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: 58		CENSUS: 19	DATE:	10/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Executive Director, Angie Smith		TIME COMPLETED:	03:45 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	At approximately 8:30AM, Licensing Program Analyst (LPAs) Chris Arnhold and Christi Coppo made an unannounced annual required inspection of the facility. LPAs met with Executive Director Angie Smith. At approximately 9:00AM, LPAs and Executive Director toured the building and grounds which was found to be clean and in good repair. LPAs observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPAs observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Combination smoke/carbon monoxide detectors were present and found to be in working order. Facility has fire sprinklers throughout and were inspected 10/12/2023. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. At approximately 11:30AM, LPAs reviewed 5 resident records and found all records have current physician's reports (LIC 602) and Appraisal Needs and Services Plans, as well as current and signed admission agreements. At approximately 1:05PM, LPAs reviewed 5 staff records. Five out of five records did not contain documentation of completed training records as required. Evidence of current first aid and CPR training were current. Continued on 809C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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 SENIOR LIVING	FACILITY NUMBER: 496803825
	VISIT DATE: 10/12/2023

NARRATIVE

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At approximately 2:30PM, LPAs reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has the required evacuation stair chairs in place. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts and documents disaster drills quarterly.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC308 Designation of Facility Responsibility

Evidence of current Liability Insurance received during visit

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Executive Director Angie Smith and Appeal rights were given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/12/2023 03:36 PM - It Cannot Be Edited

Created By: Christi Coppo On 10/12/2023 at 02:53 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 SENIOR LIVING	FACILITY NUMBER: 496803825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(c)

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs record review, the licensee did not comply with the section cited above in 5 out of 5 staff records did not maintain in the personnel records verification of required staff training and orientation, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	Licensee to submit a written plan to address staff orientation and completion of required annual training, as well as how facility will show evidence of future completed training. Plan to be submitted to CCL by POC due date of 11/10/2023.

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:

Bethany Moellers

LICENSING EVALUATOR NAME:

Christi Coppo

LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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