<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803825
Report Date: 07/11/2024
Date Signed: 07/11/2024 02:17:16 PM

Document Has Been Signed on 07/11/2024 02:17 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 SENIOR LIVINGFACILITY NUMBER:
496803825
ADMINISTRATOR/
DIRECTOR:		SMITH, ANGIEFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 58CENSUS: 23DATE:
07/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:27 PM
MET WITH:Carla Lua (Administrator)TIME VISIT/
INSPECTION COMPLETED:
02:32 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility to conduct a case management visit to cite deficiencies discovered during a complaint investigation and met with acting Administrator, Carla Lua.

LPA learned through records review that the licensee did not notify the Department of the change of administrator in writing within thirty (30) days of the hiring of a new administrator back in December 2023. During the investigation it was revealed that prior administrator has resigned in December 2023, interim administrator covered administrator’s duties during the last two weeks of December through March 2024, new administrator’s first date was March 17, 2024. 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.

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. Exit interview conducted with acting administrator and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/11/2024 02:17 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 07/11/2024 at 12:54 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: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2024
Section Cited
CCR
87211(g)

1
2
3
4
5
6
7
87211 (g) Reporting Requirements: The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to ensure that any changes to the facility will be reported as required by Title 22 Regulations # 87211. Licensee will submit LIC9098 self-certification form that they understand and compliance with regulation to CCL by POC due date.
8
9
10
11
12
13
14
Based on records review, the licensee did not notify the Department of the change of administrator in writing within thirty (30) days of the hiring of a new administrator back in December 2023, which is a potential risk to the health and safety of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2