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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 04/30/2026
Date Signed: 04/30/2026 10:05:36 AM

Substantiated


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
01/26/2026 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20260126110939
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: 44DATE:
04/30/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carla Lua, Executive DirectorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Facility is Not Maintaining Medication Records Correctly
INVESTIGATION FINDINGS:
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At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegation and met with facility Administrator Carla Lua.

During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges that the Facility is Not Maintaining Medication Records Correctly. LPA reviewed the facility’s Centrally Stored Medication and Destruction Records and observed all medications to be centrally stored and secure. LPA also reviewed Medication Administration Records (MARs) for a sample of facility residents. LPA did observe multiple instances of staff not entering their initials in the MARs to indicate that the medication has been administered. For resident R1, the MARS for medication R1M1 was not initialed on the following dates: 9/1/2025, 9/3/2025, 9/4/2025, 9/5/2025, 9/7/2025, 9/11/2025, 9/14/2025, 9/15/2025, 9/16/2025, 9/18/2025, 9/24/2025, 9/25/2025, 9/26/2025 and 9/29/2025.

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

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
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 5
Control Number 21-AS-20260126110939
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: 04/30/2026
NARRATIVE
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...Continued from 9099

For resident R2, the MARS for medication R2M1 was not initialed on the following dates: 1/5/2026, 1/6/2026, 1/7/2026, 1/8/2026, 1/15/2026, 1/29/2026, 1/30/2026, and 1/31/2026. For resident R2, the MARS for medication R2M2 was not initialed on the following dates: 9:00 AM medication pass – 1/5/2026, 1/6/2026, 1/7/2026, 1/8/2026, 1/15/2026, 1/29/2026, 1/30/2026 and 1/31/2026. 5:00 PM medication pass - 1/29/2026, 1/30/2026 and 1/31/2026. For resident R3, the MARS for medication R3M1 was not initialed on the following dates: 1/8/2026, 1/30/2026 and 1/31/2026. For resident R3, the MARS for medication R2M2 was not initialed on the following dates: 1/8/2026, 1/30/2026 and 1/31/2026. California Health and Safety Code (HSC) 1569.69 (g) states that Residential care facilities for the elderly licensed to provide care for 16 or more persons shall maintain documentation that demonstrates that a consultant pharmacist or nurse has reviewed the facility's medication management program and procedures at least twice a year. Consonus Pharmacy conducted reviews of the facility’s medication management program on 9/15/2025 and 12/17/2025. Both reviews noted that there are a “High Number of Holes” in the MARs for the quarter under review. “Holes” indicate that staff initials have not be entered when medications are administered. Based on LPA’s record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20260126110939
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2026
Section Cited
CCR
877506(a)
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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location... and to licensing agency staff.

This requirement is not met as evidenced by:
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Licensee or Administrator to provide training in Medication Management record keeping for all staff currently administering medications. Additionally, the facility will provide it’s most recent Medication Management audit to Community Care Licensing (CCL).
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Based on observation & record review, the licensee did not comply with the section cited above in that three (3) of three (3) residents (R1, R2, R3) MARs were not initialed by staff on dates noted in findings which poses a potential health, safety or personal rights risk to persons in care.
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Proof of training to include training materials and signatures of staff members attending training to be sent to CCL by POC due date of 5/28/2026.
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/26/2026 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20260126110939

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: 44DATE:
04/30/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carla Lua, Executive DirectorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Facility is Not Ensuring Medications are Given to Residents Per Doctors Orders

Facility Staff are Not Properly Trained in Medication Management
INVESTIGATION FINDINGS:
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During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges that the facility is not ensuring medications are given to the residents per the doctors’ orders. Witness W1 provided resident names and alleged examples of residents not receiving medications per doctors’ orders. Additionally, photographs of medications were sent by witness W1. The photographs sent by witness W1 only showed various medications. There were no photographs of prescription labels or any evidence that could tie the photographed medications to a specific resident. In reference to resident R1, witness W1 stated that a Federal Express package containing pro re nata (PRN-given as needed) medication was signed for by the facility receptionist on 12/27/2025 and then went missing. During records review LPA could not find any evidence of the specified medication having been recently ordered prior to the date in question or any evidence of the specified medication having gone missing.

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

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20260126110939
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: 04/30/2026
NARRATIVE
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...Continued from 9099-A

In reference to resident R2, witness W1 stated that on 1/20/2026 they received their morning medications late. LPA reviewed Medication Administration Records (MARs) for resident R2 for 1/20/2026 and observed nothing to indicate that R2’s medications were not administered at the prescribed times. In reference to resident R3, witness W1 stated that the facility is swapping out resident R3’s medication and replacing them with an over the counter (OTC) medication. A photograph of pills in a bottle was provided by witness W1. The photograph did not show prescription labels or any evidence that could tie the photograph to resident R3’s prescribed medications. In reference to resident R4, witness W1 stated that R4’s medication was being kept in a black lock box in staff member S2’s office. LPA inspected S2’s office and found no evidence of a black lock box containing medications. LPA observed the PRN medication in question to be centrally stored, secure and with proper documentation. So, 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.

Complaint alleges that the Facility Staff are Not Properly Trained in Medication Management. During the course of the investigation there were six (6) staff members designated as Med Aids who were responsible for administering medication to residents. California Health and Safety Code (HSC) 1569.69 states that in facilities with sixteen (16) or more residents, each employee of the facility who assists residents with the self-administration of medications shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction. Additionally, employees who continue to assist with the self-administration of medications shall also complete eight hours of in-service training on medication related issues in each succeeding 12-month period. LPA reviewed training documentation and course materials for the facility’s six (6) Med Aides. LPA observed that the Med Aides had taken all required initial training and continuing training. So, 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.

Exit interview conducted. Copy of LIC 9099, LIC 9099D, LIC 9099S and Appeal Rights discussed and provided to Administrator Lua. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5