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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 03/11/2022
Date Signed: 03/11/2022 03:40:31 PM

Substantiated


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
01/27/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220127123704
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
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Acting Administrator, Lisa DiBartoloTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Insufficient Staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrive unannounced to deliver findings regarding the above-mentioned compliant allegations and met with Acting Administrator, Lisa DiBartolo.

Insufficient Staffing – Complaint alleges that staff is not sufficient enough to provide for resident’s care needs. Interviews indicated that one resident waited 45 minutes for staff assistance with getting dressed and another indicated that sometimes they do not get their shower timely as the facility is short staffed. Review of files revealed that at least twice per week there is one staff on the overnight shift for both Assisted Living and Memory Care.

The allegation of Insufficient Staffing is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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
01/27/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220127123704

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
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Acting Administrator, Lisa DiBartoloTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Resident is not being properly fed
Staff mishandles resident's medications
Facility is not being maintained in a safe and sanitary manner
Resident sustained a fall while in care
Staff do not meet a resident's incontinence needs
Resident's laundry needs are not being met
Staff are not following a resident's needs and services plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrive unannounced to deliver findings regarding the above-mentioned compliant allegations and met with Acting Administrator, Lisa DiBartolo.

Licensing Program Analyst Willis arrive unannounced to deliver findings regarding the above-mentioned compliant allegations and met with Acting Administrator, Lisa DiBartolo.

Resident is not being properly fed – Complaint alleges that resident sleeps late, is not encouraged by facility staff to come down for meals or eat the meals that are brought to their apartment resulting in resident losing weight. Doctor’s report indicated that resident was able to feed themselves. Resident assessment noted that resident needed meal reminders. Per interviews, resident R1 sleeps until the late morning and facility leaves breakfast on R1’s night stand adding that resident usually comes down to the dining room for lunch. Per staff interviews, staff attempt to get R1 up in the mornings but resident refuses.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20220127123704
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 AT CLOVERDALE
FACILITY NUMBER: 496803825
VISIT DATE: 03/11/2022
NARRATIVE
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Continued from LIC9099A

Staff mishandles resident's medications – Complaint alleges that resident was given incorrect dosage when they initially moved into the facility indicating that medication for blood pressure was given twice per day when it was supposed to be given once per day and that medications were sometimes left in R1’s room while they were sleeping. Per interviews, upon move-in, medications were not in their original containers causing facility Administrator and responsible party to have to meet and organize medications. Interviewed staff denied leaving medications in resident rooms and stated that they stay with the resident until the medications are taken. Review of the documents pertaining to medications showed that blood pressure medication was to be given twice per day.

Facility is not being maintained in a safe and sanitary manner – Complaint alleges that resident’s mattress did not have a mattress cover on it resulting in the mattress being stained by urine and that the carpet was stained and retained a urine odor. Additionally, that resident’s bathroom was not cleaned as needed and food was left around the apartment. Per staff interviews, the facility cleaned the mattress with an industrial cleaner and staff did not observe urine on the carpeted floor. LPA observed that involved resident’s room did not smell of urine during February 2, 2022 visit. Resident’s mattress had a faint stain but did not smell of urine. LPA did not observe any stains on the carpet. Administrator confirmed that there was not a mattress cover on the mattress due to it being in the wash. Per interviews, resident rooms are cleaned once per week and those who receive laundry services have their laundry cleaned once per week. Additional laundry services are provided, if needed, and caregivers are instructed to clean when housekeeping is unavailable.

Staff do not meet a resident's incontinence needs – Complaint alleges that resident’s incontinence needs are not being met including but not limited to not changing resident in the morning, not putting incontinence briefs on resident and not assisting them to the restroom. Staff interviews indicate that resident prefers to sleep late in the mornings and refuses to allow staff to change them or assist them to the restroom. Staff indicated that they did put incontinence briefs on resident and laundered them 2-3 times per week to reduce odor in resident’s apartment.

Resident sustained a fall while in care – Complaint alleges that resident fell while in care and LPA confirmed through a facility self-report that resident did have a fall and was sent to the hospital. Review of resident’s care plan did not indicate that resident required one-to-one supervision.

Resident's laundry needs are not being met – Complaint alleges that resident’s laundry was not being done frequently enough to ensure that resident’s clothes and linens remained free of odor. Per interview with staff, facility increased laundry from once per week to twice per week to assist in reducing the smell of urine. Additionally, Administrator indicated that staff were instructed to do resident’s laundry as often as was needed to ensure resident’s room was free of odor.

Staff are not following a resident's needs and services plan – Complaint alleges that facility did not assess resident accurately upon move in. Based on review of facility’s initial resident assessment, resident R1 was deemed independent for most activities of daily living but required standby assistance when bathing and did use a walker when ambulating. Preplacement appraisal noted mobility issues and trouble walking. Resident’s doctor’s report that was completed prior to move-in indicated that resident was able to dress and groom themselves, toilet themselves and transfer independently but needed assistance with bathing. Following a fall and subsequent hospital stay, resident was reassessed and additional needs were noted in an updated care plan that included increased supervision, assistance with dressing, assistance to meals and increased reminders. Per interview with Administrator, the facility was providing for the increased care needs.

A finding that the complaint allegations that resident is not being properly fed, staff mishandles resident's medications, facility is not being maintained in a safe and sanitary manner, resident sustained a fall while in care, staff do not meet a resident's incontinence needs, resident's laundry needs are not being met and staff are not following a resident's needs and services plan were unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegations occurred.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20220127123704
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 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
87411
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs. In facilities licensed for 16 or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608...
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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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This requirement has not been met based on document review and interviews indicating that facility is short staffed resulting in needs being delayed or not met. 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4