496803825-10-27-2026-21-AS-RFRK-DZ9TY4-20261027150807

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803825
Report Date: 10/27/2026
Date Signed: 10/27/2026 03:08:16 PM

Document Has Been Signed on 10/27/2026 03:08 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 LIVING		FACILITY NUMBER:	496803825
ADMINISTRATOR/ DIRECTOR:	Jennifer Lee Hall		FACILITY TYPE:	740
ADDRESS:	247 Treadway DR		TELEPHONE:	(707) 791-4787
CITY:	Cloverdale	STATE: CA	ZIP CODE:	95425
CAPACITY: 58		CENSUS: 51	DATE:	10/27/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Jennifer Mannel, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

NARRATIVE

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At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required inspection and was greeted by newly appointed Executive Director (ED), Jennifer Mannel. Vine Ridge Senior Living serves older adults in Assisted Living and Memory Care. The facility has a plan of operation for dementia care and programming on file. The facility has an approved fire clearance and total capacity for ninety-nine (99) ambulatory and non-ambulatory residents, eight (8) of whom may be bedridden. Facility has an approved hospice waiver for eight (8) residents. The facility consists of a multi-level building with multiple outside patio areas. The Memory Care unit has it's own dedicated patio and garden area. Upon arrival, LPA was informed that there were thirty-six (36) residents in assisted living and fifteen (15) residents in Memory Care for a total of fifty-one (51) Residents in care. LPA reviewed the Facility's Staff Roster and observed staff member S1 had not been cleared on the Guardian Background Check system. The Facility will be cited for this deficiency. A Civil Penalty of $100 will be issued for this deficiency. LPA observed that all other staff were background cleared and associated to the facility per regulation.

At approximately 12:15 PM, LPA reviewed five (5) resident files. Five (5) of five (5) resident files were observed with all required documentation.

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

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, LIC-421BG and Appeal Rights discussed and provided to ED Mannel. Signature on form confirms receipt of documents.

Victoria Bertozzi
Robert Frank
	DATE: 10/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2026

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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Document Has Been Signed on 10/27/2026 03:08 PM - It Cannot Be Edited

Created By: Robert Frank On 10/27/2026 at 02:28 PM

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: 10/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(d)(3)

(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. (3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in that Staff Member S1 did not receive Guardian Background Clearance prior to employment at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/17/2026
	Plan of Correction
1 2 3 4	Licensee or Administrator will submit an LIC 9098 Proof of Correction self certifying that staff member S1 will not work at the facility until they have received Guardian background fingerprint check clearance or provide proof that staff member S1 has received Guardian Background Check clearance to Community Care Licensing by POC due date of 11/17/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 10/27/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2026

LIC809 (FAS) - (06/04)

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