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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 08/11/2026
Date Signed: 08/11/2026 02:51:55 PM

Unsubstantiated


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
05/29/2026 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20260529081037
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: 43DATE:
08/11/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carla Lua, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident sustained an injury while in care due to inadequate supervision and lack of a safe environment

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 allegations and met with facility Executive Director (ED) Carla Lua.

During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges that Resident sustained an injury while in care due to inadequate supervision and lack of a safe environment. On 5/29/2026, Community Care Licensing (CCL) received two anonymous complaints. Both complaints contained the same information. The reporting parties (RPs) stated that resident R1 injured themselves while on a facility outing on 5/26/2026. Three (3) residents went on the outing. The facility submitted an LIC 624 Unusual Incident/Injury Report (IR) on 5/29/2026. The IR was submitted within the required seven (7) day window. Both the RP and the facility IR state that R1 was seated at the rear of the van.

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

DATE: 08/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
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-20260529081037
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: 08/11/2026
NARRATIVE
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...Continued from 9099

Through interview LPA ascertained that the facility allows ambulatory residents to sit in the rear seats while non-ambulatory residents sit at the seats directly next to the van’s side doors. Resident R1’s LIC 602A Physician’s Report lists R1 as being ambulatory. While exiting the van, resident R1 got their foot caught in the back of the seat next to the side door and hurt their knee. Staff member S1 who was accompanying/driving the residents immediately called the facility to report the incident and emergency services were notified. Facility ED Lua drove to the location where the incident occurred. Emergency services arrived on the scene and recommended that resident R1 be transported to the hospital for further examination. Emergency Services reported that their ambulance was already transporting someone to the hospital. Emergency services suggested that the facility transport R1 to the hospital for expediency. The facility then transported R1 to Providence Healdsburg hospital. Resident R1 was diagnosed with a minor knee injury that did not require any surgery or casting. Resident R1 returned to the facility later the same day. Resident R1 has had no further complications resulting from their injury on 5/26/2026. LPA examined the facility van and found no safety hazards. LPA reviewed staff member S1’s training file and observed that S1 has completed all required annual training including fall prevention. LPA could not find any evidence of a lack of supervision or of an unsafe environment for residents. 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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
05/29/2026 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20260529081037

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: 43DATE:
08/11/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carla Lua, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff falsify reports
INVESTIGATION FINDINGS:
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Complaint alleges that Staff falsify reports. RP stated that staff member S1 intended to falsify the Incident Report by stating that the resident fell at the facility and not at the outing. LPA interviewed multiple staff members including staff member S1. Additionally, LPA reviewed the facility internal charting notes regarding R1 and the incident. LPA could not find any evidence whatsoever indicating that S1 or the facility tried to falsify documents.

This agency has investigated the complaint alleging that Staff falsify reports. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. Copy of LIC-9099, LIC-9099C and LIC-9099A discussed and provided to ED Lua. Signature on form confirms receipt of documents.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3