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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 09/05/2025
Date Signed: 09/05/2025 04:24:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
09/03/2025 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20250903150111
FACILITY NAME:VINE RIDGE SENIOR LIVINGFACILITY NUMBER:
496803825
ADMINISTRATOR:LUA, CARLAFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:99CENSUS: 38DATE:
09/05/2025
UNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Carla LauTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Physical plant in disrepair
INVESTIGATION FINDINGS:
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At approximately 8:50 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to initiate and deliver a finding for a Complaint Investigation regarding the above allegation and met with facility Administrator Carla Lau.

Complaint alleges that the floor in the memory care dining/common area is in disrepair. A witness stated that it is dangerous to the residents as the damaged floor is a trip hazard. During LPA's inspection of the memory care dining/common area LPA observed a large portion of the floor in disrepair. The synthetic flooring strips were bubbled and loose. The ends of the flooring strips were observed to be raised. LPA further observed that it appeared that tape was at one point used to secure the flooring. Facility administrator Lau stated the floor had been in disrepair for approximately three (3) months. LPA obtained photographs of the damaged floor area. The facility is planning to replace the damaged flooring during the weekend of 9/19/2025 to 9/21/2025.
Continued on 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20250903150111
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
NARRATIVE
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...Continued from 9099

Based on LPA’s observation and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

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, LIC9099, 9099C, 9099D, Plan of Corrections and Appeal Rights discussed and provided to ED Lau. Signature on form confirms receipt of documents

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20250903150111
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance...for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Licensee to provide plans on what is being done mitigate the trip hazard in the memory care dining/common area floor to Community Care Licensing by POC due date of 9/9/2025. Licensee will also provide photographs of the repaired floor as soon the floor repair is completed.
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Based on observation & interview, the licensee did not comply with the section cited above in that a large portion of the floor in the memory care dining/common area floor was in disrepair. The flooring strips were bubbled and loose which poses a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4