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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803825
Report Date: 03/11/2022
Date Signed: 03/11/2022 03:45:08 PM

Document Has Been Signed on 03/11/2022 03:45 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:UBALLEZ, DAVIDFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 58CENSUS: 20DATE:
03/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:59 PM
MET WITH:Acting Administrator, Lisa DiBartoloTIME COMPLETED:
03:55 PM
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Licensing Program Analyst Willis arrive unannounced to conduct a Case Management inspection and met with Acting Administrator, Lisa DiBartolo.

LPA is following up on an incident where a resident in Memory Care eloped the facility. Per interview with Acting Administrator, the two staff on shift were tending to other residents and did not respond to the delayed egress alarm. After eloping the resident walked to the nearby neighborhood and a neighbor called local law enforcement who then contacted the facility.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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Document Has Been Signed on 03/11/2022 03:45 PM - It Cannot Be Edited


Created By: Victoria Willis On 03/11/2022 at 03:05 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 AT CLOVERDALE
FACILITY NUMBER: 496803825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2022
Section Cited
CCR
87705

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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement has not been met
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Administrator agrees to submit staffing plan that includes use of staffing agencies, if necessary, to ensure resident's needs are met timely by POC due date, 3/12/2021.
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as evidenced by interview and document review indicating that a resident in Memory Care eloped the facility and staff did not respond to the delayed egress alarm. This is an immediate risk to the health and safety of residents 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.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Willis
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022


LIC809 (FAS) - (06/04)
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