496803825-10-15-2026-21-AS-VBEI-DZ5ULS-20261023154112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 10/15/2026
Date Signed: 10/15/2026 03:21:27 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
09/21/2026 and conducted by Evaluator Robert Frank

COMPLAINT CONTROL NUMBER: 21-AS-20260921095403

FACILITY NAME:	VINE RIDGE SENIOR LIVING		FACILITY NUMBER:	496803825
ADMINISTRATOR:	LUA, CARLA		FACILITY TYPE:	740
ADDRESS:	247 TREADWAY DRIVE		TELEPHONE:	(707) 791-4787
CITY:	CLOVERDALE	STATE: CA	ZIP CODE:	95425
CAPACITY:	58	CENSUS: 47	DATE:	10/15/2026
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jennifer Hall, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff left resident unsupervised while in the community

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 a facility visit, conducted interviews, collected and reviewed documents.

Complaint alleges that facility staff left a resident (resident R1) unsupervised while in the community. On Saturday, 9/12/2026 the facility took some residents on an outing to the Annual Cloverdale Care Show. Two (2) staff members, S1 and S2, accompanied eight (8) residents to the car show. One (1) of the facility residents was from the Memory Care (MC) unit. The residents were not signed out of the facility on the facility “Resident Sign Out/In” sheet per facility protocol.

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 3

Control Number 21-AS-20260921095403

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

Also accompanying the residents was a family member of a former resident and a family member of a current resident of the facility. According to witness testimony the facility bus arrived at the event at approximately 10:00 AM. Staff member S1 stated that they planned to leave the event at approximately 11:30 AM to get the residents back to the facility for lunch. The bus was parked in front of the Cloverdale Police station. When asked how the group moved through the event, staff member S1 stated that staff member S2 was in the lead and that they were in the back of the group accompanying the one (1) MC resident. A witness reported that some of the residents wanted to look at different vehicles featured in the event. Staff member S1 stated that, “we told everyone to meet at the popcorn stand at 11:15 AM”. At approximately 11:15 AM a witness reported that resident R1 was seen near the popcorn stand at that staff members told R1 that the group was getting ready to leave. A witness reported that R1 stated, “I am a grown redacted, don’t tell me what to do.” The redacted word identifies the gender of R1. As staff members gathered residents at the facility bus, they then realized that R1 was not with the group. Staff stated that they searched for R1 at the event for approximately thirty (30) minutes and then began to load the bus. Off duty staff member S4, who was attending the event on their free time, also helped in the search. Resident R1 was not found during the search. Staff then stated that they called the facility and told them that they were unable to find R1 and that the facility should call them if they see R1. Staff members reported that as they were loading the bus, the facility called them and stated that R1 was returned to the facility by an unidentified person. In an interview staff member S3 corroborated that R1, “decided to walk back on their own”. In an interview, resident R1 was unable to recall the events of 9/12/2026 due to a cognitive condition. Resident R1’s LIC602A Physician’s Report for Residential Care Facilities for the Elderly listed a diagnosis of Dementia. Additionally, R1’s LIC602A stated that R1 is not able to leave the facility unassisted. As such, R1 should not have been left unattended outside of the facility.
Based on LPA’s interviews & record review and 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.

Exit interview conducted. Copy of report, LIC-9099, LIC-9099C, LIC-9099D, 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)

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Control Number 21-AS-20260921095403

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 B 11/05/2026 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights... (a)...shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications...to meet their needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee or Administrator to provide an updated plan on how the facility will ensure residents' safety during excursions outside of the facility to Community Care Licensing by POC due date of 11/5/2026.
	8 9 10 11 12 13 14	Based on interview & record review, the licensee did not comply with the section cited above in that R1 was left unattended outside of the facility which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
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	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: 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)

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