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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 11/07/2025
Date Signed: 11/07/2025 09:12:18 AM

Unsubstantiated


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: 36DATE:
11/07/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Alexis Short, Resident Care CoordinatorTIME COMPLETED:
09:20 AM
ALLEGATION(S):
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Insufficient staffing

Facility staff did not meet resident’s care needs
INVESTIGATION FINDINGS:
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At approximately 8:50 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegations and met with Alexis Short, Resident Care Coordinator.

During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents.

Complaint alleges the facility did not have sufficient staffing and that the facility did not meet the resident’s care needs. Resident R1 resides in the facility’s Memory Care unit. Resident R1 has been admitted to hospice services. Upon viewing resident R1’s Care Plan prepared by the facility, LPA observed that R1 requires a one (1) person assist for most daily activities.

Continued on 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
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 2
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: 11/07/2025
NARRATIVE
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...Continued from 9099

Resident R1’s Care Plan prepared by the hospice program was also observed to state that R1 requires assistance with most daily activities. LPA reviewed facility staff time sheets for the period of 8/1/2025 through 8/30/2025. The facility has three (3) defined shifts. The AM shift is 6:00AM-2:30PM. The PM shift is 2:00PM-10:30PM. The Night (NOC/Nocturnal) shift is 10:00PM-6:30AM. During the time frame noted the AM shift was observed to typically have four (4) to five (5) staff members providing care. There were several AM shifts that were observed to have six (6) or seven (7) staff members providing care. During the time frame noted the PM shift was observed to typically have four (4) staff members providing care. The PM shift was observed to typically have three (3) to four (4) staff members providing care. The NOC shift was observed to have three (3) staff members providing care. During the time frame observed (8/1/2025-8/30/2025) there was adequate staffing levels to help R1 with their daily care needs. LPA interviewed R1’s Hospice Case Manager with Sutter’s Care at Home program. The case manager stated they think the facility is meeting the care needs of their hospice residents and that the facility cares about the level of care they provide. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during today's visit.



Exit interview conducted. Copy of report discussed and provided to Resident Care Coordinator Short. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2