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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803825
Report Date: 10/28/2024
Date Signed: 10/28/2024 04:09:51 PM

Document Has Been Signed on 10/28/2024 04:09 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 LIVINGFACILITY NUMBER:
496803825
ADMINISTRATOR/
DIRECTOR:		SMITH, ANGIEFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 99CENSUS: 26DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Alexis Short-Resident Care CoordiantorTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required - 1 Year visit, on 10/28/24 at approximately 9:45am, and met with Resident Care Coordinator (RCC) Alexis Short. The facility is a licensed assisted living, community, which includes a memory care unit.

Hospice care waiver approved for eight (8) residents. Facility has an approved dementia plan of operation. Facility has a required infection control plan, and a required emergency disaster plan. Fire clearance approval is for ninety-nine (99) non-ambulatory of which eight (8) may be bedridden; Bedridden is fire cleared for the first floor only.

The facility is holding required emergency disaster drills, last two were held on April 19, and July 15, 2024. LPA discussed with RCC that the emergency disaster drills are to be held quarterly, and to ensure one is an evacuation drill; The quarterly emergency disaster drills are to be held on each shift.

LPA reviewed five (5) resident records. All records were complete.
The LPA reviewed five (5) staff records. All staff have criminal record clearance as required by regulation. Staff have first aid and CPR certification as required. LPA reviewed staff training; LPA discussed with RCC organizing proof of training, ensuring all staff are meeting the training requirements by H&S Code. LPA discussed ensuring administration staff have a plan on who is able to access the training information when the Licensee and/or the Administrator are not on-site.

LPA toured the facility with RCC Alexis. Facility was observed to be clean, orderly, and at a comfortable temperature. LPA observed exits free from obstruction. LPA observed random fire extinguishers which were serviced and tagged, expires 10/11/25. Combination smoke/carbon monoxide detectors were present and in working order. Facility is fire sprinkled throughout. Common areas, hallways, and bathrooms observed by the LPA had sufficient lighting available to residents in care. All notices that are required to be posted have been posted and are in a highly visible area.
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VINE RIDGE SENIOR LIVING
FACILITY NUMBER: 496803825
VISIT DATE: 10/28/2024
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The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility had sufficient supply of food, water, and other emergency supplies to meet the seventy-two (72) hour shelter in place requirements. LPA observed that each stairwell, two (2) had required evacuation chairs, and the large open staircase from the second floor down, also has an evacuation chair to the side of it. Facility had a sufficient supply of cleaners/disinfectants, paper products, hygiene products, and personal protective equipment (PPE). All disinfectants/cleaners were stored and secured, inaccessible to residents in care. Medications were observed and reviewed; All medications were stored in compliance with State and Federal requirements. All outside courtyards were clean, orderly, and had outside furnishings, and shaded areas for resident use.

LPA is requesting the following documents be updated and submitted by 11/28/24:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of Current Liability Insurance
Copy of current Administrator Certificate

There are no deficiencies cited during today's visit.
Exit interview conducted with RCC Alexis Short.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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