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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803825
Report Date: 04/15/2026
Date Signed: 04/15/2026 12:35:15 PM

Document Has Been Signed on 04/15/2026 12:35 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VINE RIDGE SENIOR LIVINGFACILITY NUMBER:
496803825
ADMINISTRATOR/
DIRECTOR:		LUA, CARLAFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 99CENSUS: DATE:
04/15/2026
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Carla Lua, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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An Office meeting was conducted today, 04/15/2026, in the Santa Rosa Regional Office. The following individuals were present at the meeting: Victoria Bertozzi, Licensing Program Manager; Robert Frank, Licensing Program Analyst; Larona Farnum, Chief Operating Officer of Western Living Concepts and Carla Lua, Executive Director.

The purpose of the office meeting was to hold an Informal discussion to address the following areas of concern identified by the Department.
  • Reporting Requirements: Submitting Incident Reports (IRs); Missing IRs from 2025; Submitting IRs with complete information.
  • Seeking Timely Medical Care for Residents. IRs received by Community Care Licensing (CCL) state that facility staff called residents’ family members for direction regarding notification of Emergency Services.
  • Facility Medication Management: Staff training in new medication policies received by Community Care Licensing on 3/19/2026.
  • Fire Safety issues and Personal Rights concerns regarding Assisted Living Waiver (ALW) residents sharing rooms.
  • Medical Renewals for residents on ALW.

On 1/9/2026 during a facility visit to initiate a complaint investigation (complaint 21-AS-20260102134135), LPA Frank observed an After Visit Summary from Providence Healdsburg Hospital Emergency Center for the date of 10/20/2025 for resident R1 in R1’s facility file.

Continued on 809-C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/15/2026
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,,,Continued from 809

The After Visit Summary stated that R1 had suffered an injury. On 10/20/2025 resident R1 was a resident of the facility. Community Care Licensing did not receive an IR for this injury. Under California Code of Regulations, Title 22, Division 6, Chapter 8, Article 4 Operating Requirements, 87211 Reporting Requirements (a)(1)(B) state that a written report shall be submitted to the Licensing Agency for any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. As no IR was submitted to CCL for this event, the facility will be cited for this deficiency.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. 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, LIC-809D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Executive Director Lua. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2026 12:35 PM - It Cannot Be Edited


Created By: Robert Frank On 04/15/2026 at 09:19 AM
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: 04/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2026
Section Cited
CCR
87211(a)(1)(B)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing agency...(B) Any serious injury...while the resident is under facility supervision.
This requirement is not met as evidenced by:
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Licensee or Administrator will submit facility policies and processes for submitting Incident Reports to Community Care Licensing within the regulated time frame. Additionally, the facility will train all staff members on these policies and processes.
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Based on observation & record review, the licensee did not comply with the section cited above in that an Incident Report was not Submitted for R1 for an injury sustained at the facility which poses a potential health, safety or personal rights risk to persons in care.
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These policies and processes and proof of staff training are to be submitted to Community Care Licensing by POC due date of 5/13/2026.

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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2026


LIC809 (FAS) - (06/04)
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