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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 07/11/2024
Date Signed: 07/11/2024 02:15:21 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/07/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240507093626
FACILITY NAME:VINE RIDGE SENIOR LIVINGFACILITY NUMBER:
496803825
ADMINISTRATOR:SMITH, ANGIEFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:58CENSUS: 23DATE:
07/11/2024
UNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Carla Lua (Administrator)TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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-Facility did not have a certified administrator.
-Staff are not properly trained .
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with acting administrator Carla Lua.

An allegation was received by the Department regarding facility did not have a certified administrator. Per Reporting Party, acting administrator was hired in December 2023 as the facility administrator and admitted to reporting party of not having an administrator certificate. The reporting party states acting administrator began taking their administrator classes earlier this year and is not sure if they have applied for the certificate. Based on records review, prior administrator has resigned in December 2023, new administrator’s first date was March 17, 2024. Although, the acting administrator do not have a current administrator certificate and is currently in the administrator certification section pending review list of the Department as of March 28, 2024, and application was received on April 2, 2024.

Continue on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20240507093626
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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 SENIOR LIVING
FACILITY NUMBER: 496803825
VISIT DATE: 07/11/2024
NARRATIVE
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Continued from LIC9099...
However, LPA was provided with interim certified administrator Larona K Farnum certificate #6020540740 expires on 10/1/24, who confirmed during interviews conducted with LPA, that they were present in the facility in average of 15-20 hours per week depending on administrator’s duties needed, during the last two weeks of December 2023 through March 2024. LPA will address reporting requirements on a case management due to the licensee did not notify the Department in writing within thirty (30) days of the hiring of a new administrator. On April 29, 2024, the Department received pertinent documentation dated April 29, 2024, from the Board of Directors Western Living Concepts, Inc appointing new administrator and requesting the Department to change administrator’s name on file.


The Department received an allegation of facility staff are not properly trained. Reporting Party states housekeeping staff have been now assigned to provide care giving services to the residents without having trainings. Per the reporting party, current acting administrator gives some staff special treatment and does not let some staff take their break or lunch. The reporting party did not have further details to provide. Based on visits conducted on 5/16/24, 6/5/24 and 6/11/24 staff were present and appeared to be sufficient staff to meet resident’s needs. Based on records review, LPA obtained staff schedule for the month of May 2023, where it was determined that there are an average of two caregivers and a medication technician assigned to the morning and afternoon shift. The night shift usually has two caregivers for a census of 20 residents in care. Based on review of staff (S1, S2, S3, S4, S5, S6, S7, S8, S9 & S10) training records, six out of six staff who assist in the administration of medications have the required training per regulation. Four out of six caregiver staff who assist residents with a diagnosis of dementia have at least twenty hours average of training hours required per regulation. LPA was provided with assignment sheet designed for two groups (Group A & Group B) of caregivers, which revealed that caregivers are supposed to take staggered lunches to always ensure coverage. LPA conducted on 6/5/24 and 6/11/24 confidential interviews with staff (S1-S10) including kitchen staff revealed that some staff assist residents when they are at the dining room and at times, they do escort them to their room, but they do not necessarily assist residents with toileting, medication, etc. LPA learned based on records review and interviews with staff, information was not provided to support that violation occurred regarding facility staff are not properly trained. A finding that the complaint allegation of facility staff is not properly trained is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No citations during today's visit. Exit interview was conducted with acting administrator and a copy of this report was given.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
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