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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 10/15/2026
Date Signed: 10/15/2026 03:25:31 PM

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
07/03/2026 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20260703103248
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:58CENSUS: 47DATE:
10/15/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennifer Hall, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Medications not administered as prescribed

INVESTIGATION FINDINGS:
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At approximately 9:00 AM Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegation and met with facility Administrator Jennifer Hall.

During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents.

Complaint alleges that medications were not administered as prescribed. On Friday 6/26/2026, facility staff member S2 contacted Sutter Senior Care Clinic regarding a change in the condition of resident R1. Based on their conversation with S2, a Care Coordinator from Sutter then consulted with R1’s primary care physician (PCP) who prescribed two (2) medications for R1 to begin taking immediately as R1 was at a high risk for decompensation and hospitalization.

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

DATE: 10/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2026
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 4
Control Number 21-AS-20260703103248
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: 10/15/2026
NARRATIVE
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...Continued from 9099

On the same day 6/26/2026, the clinic called the facility to notify them of the prescription and to schedule a follow-up appointment during the following week. The clinic was told that facility Executive Director (ED) Carla Lua was not available and that facility Resident Care Coordinator (RCC) would return their call. The facility did not return their call on 6/26/2026. On Monday 7/1/2026, Sutter Care Coordinator W1 called the facility to check on R1’s status and to schedule a follow-up appointment. W1 spoke with staff member S3 who was unable to confirm if R1 had begun taking the medications prescribed on 6/26/2026. W1 then called R1’s pharmacy who stated that the prescribed medications have not been picked up by the facility. Later on 7/1/2026, W1 spoke with the facility’s RCC who scheduled an appointment for R1 for the following day 7/2/2026. According to facility staff member S2, the medications were picked after R1’s 7/2/2026 appointment where upon R1 began taking the medications prescribed on 6/26/2026.
LPA was contacted by witness W2 on 7/2/2026 regarding concerns related to the facility changing it’s primary pharmacy. W2 is the responsible party for resident R3. The facility was changing their primary pharmacy from Consonus Pharmacy to Galt Pharmacy. W2 was given a form by the facility ED Lua. The form was from Galt Pharmacy and the top of the form had listed, “Patient Sign-Up”. W2 expressed concerns to ED Lua that they did not want R3’s pharmacy changed to Galt Pharmacy. ED Lua assured W2 that they were using the form just to compile a profile and that R3’s pharmacy of choice would not be changed. Subsequently, R3’s pharmacy was changed to Galt Pharmacy. W2 stated that it took multiple calls over several days to have R3’s pharmacy changed back to their pharmacy of choice. Approximately three (3) weeks later R3’s pharmacy was changed again to Galt Pharmacy. W2 stated that after multiple calls over several days it was once again changed back to their pharmacy of choice. The events regarding R3’s un-requested pharmacy change were corroborated by staff member S4.
On 7/31/2026, Community Care Licensing (CCL) received an LIC 624 Unusual Incident/Injury Report (IR) submitted by the facility. The IR stated that on 6/25/2026 a prescription medication for resident R4 was finished and that there was, “no supply of the medication remaining”. The IR further stated that multiple requests were made to the facility’s pharmacy to refill the medication. Per the IR submitted to CCL on 7/31/2026, four (4) days after the medication was depleted the resident’s responsible party was contacted. R4’s responsible party instructed the facility to contact R4’s PCP regarding a refill request. R4’s PCP refilled the prescription on 7/2/2026. R4 did not receive this prescription medication for six (6) days.

Continued on 9099-C2...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20260703103248
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: 10/15/2026
NARRATIVE
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...Continued from 9099-C

Based on LPA’s interviews, record review and express admission 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. As the facility was previously cited for the same deficiency on 3/12/2026 a Civil Penalty of $250 is being issued.

Exit interview conducted. Copy of LIC9099, LIC9099C, LIC9099-C2, LIC9099D, LIC421FC, Plan of Corrections and Appeal Rights discussed and provided to Administrator Hall. Signature on form confirms receipt of documents.

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

DATE: 10/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20260703103248
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: 10/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2026
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed...by compliance with the following:(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Licensee is to have a 3rd party pharmacy or pharmacy consultant complete a full audit of the facility’s medications and medication management program. Licensee to provide Community Care Licensing
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Based on interviews, record review & express admission, the licensee did not comply with the section cited above in that there were three (3) instances where the facility had medication management errors (please refer to the LIC9099s) which poses an immediate health, safety or personal rights risk to persons in care.
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the name of the 3rd party pharmacy or pharmacy consultant, audit findings and the date on which the audit will be conducted to Community Care Licensing by POC due date of 10/16/2026.
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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.
SUPERVISOR'S NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4