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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803825
Report Date: 09/05/2025
Date Signed: 09/05/2025 04:18:09 PM

Document Has Been Signed on 09/05/2025 04:18 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:		LUA, CARLAFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 99CENSUS: 38DATE:
09/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Carla Lau, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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At approximately 8:50 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required inspection and was greeted by Administrator/Executive Director (ED), Carla Lau. Vine Ridge Senior Living serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for ninety-nine (99) ambulatory and non-ambulatory residents. Facility has an approved hospice waiver for eight (8) residents. The facility consists of a multi-level building with multiple outside patio areas. The Memory Care unit has it's own dedicated patio and garden area. Upon arrival, LPA was informed that there were twenty-three (23) residents in assisted living and fifteen (15) residents in Memory Care for a total of thirty-eight (38) Residents in care. At approximately 9:25 AM, LPA reviewed Facility Staff Roster and found that staff member S1 had not been cleared in the Guardian Background check system. A citation will be issued for this deficiency. A Civil Penalty of $100 will be assessed for this deficiency. All other staff members on site were background cleared and associated to the facility per regulation.

At approximately 10:25 AM LPA toured the facility with Resident Care Coordinator, Alexis Short. The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offers a variety of menu options for the residents at each meal. There is also a variety of fresh fruit and other snacks available for residents at all times. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care.


Continued on 809-C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/05/2025
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...Continued from 809

Hot water temperatures for a sample size of nine (9) sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. All stairwells had evacuation chairs per regulation.

The building's smoke and carbon monoxide detectors and sprinkler system were last inspected in 2/2025. All exits were observed to be unobstructed. All fire extinguishers were serviced and tagged in 10/2024. The facility conducts disaster drills quarterly. The last disaster drill was conducted on 6/25/2025.

During inspection of memory care unit LPA observed the flooring in the common area/dinning area to be in disrepair. This deficiency will be cited on complaint 21-AS-20250903150111. The facility is planning to replace the damaged flooring during the weekend of 9/19/2025 to 9/21/2025.

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.



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.

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, LIC421BG, LIC811 Confidential Names and Appeal Rights discussed and provided to ED Lau. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2025 04:18 PM - It Cannot Be Edited


Created By: Robert Frank On 09/05/2025 at 02:49 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: 09/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(d)(3)
Criminal Record Clearance
(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that Staff Member S1 did not receive Guardian Background Clearance prior to employment at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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Licensee or Administrator will submit an LIC 9098 Proof of Correction self certifying that staff member S1 will not work at the facility until they have received Guardian background fingerprint check clearance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2025


LIC809 (FAS) - (06/04)
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