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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 06/23/2022
Date Signed: 06/23/2022 03:16:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/03/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220503151514
FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:UBALLEZ, DAVIDFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:58CENSUS: 22DATE:
06/23/2022
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Administrator, Licensee, Larona Farnum and Acting Administrator, Rachael LanhamTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Facility failed to ensure resident's personal rights
INVESTIGATION FINDINGS:
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Licensing Program Manager Willis arrived unannounced to deliver findings regarding the above mentioned complaint allegations and met with Administrator, Licensee, Larona Farnum and Acting Administrator, Rachael Lanham.

During investigation LPA conducted interviews, reviewed documents and made observations.

Facility failed to ensure resident's personal rights – Complaint alleges that a resident takes the clothes of other residents and wears them, and another resident lays down in other resident’s beds. Additionally, complaint alleges that resident hits other residents and staff. Three of four staff interviews identified two residents who go into other residents’ rooms and confirmed instances of resident’s taking other resident’s clothes and laying in other resident’s beds. Two of four interviewed staff indicated that they have observed resident, R1 hit other residents.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/03/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220503151514

FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:UBALLEZ, DAVIDFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:58CENSUS: 22DATE:
06/23/2022
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Administrator, Licensee, Larona Farnum and Acting Administrator, Rachael LanhamTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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9
Facility retained a resident with a prohibited condition
Facility failed to meet resident's care needs
INVESTIGATION FINDINGS:
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Licensing Program Manager Willis arrived unannounced to deliver findings regarding the above mentioned complaint allegations and met with Administrator, Licensee, Larona Farnum and Acting Administrator, Rachael Lanham.

During investigation, LPA conducted interviews, reviewed documents and made observations.

Facility retained a resident with a prohibited condition – Complaint alleges that the facility retained a resident with a staph infection. Review of discharge paperwork from hospital indicated that resident, R1 was diagnosed with a “local infection of the skin and subcutaneous tissue, unspecified” and was being treated with an antibiotic for “possible chronic staph infection”. Based on review of medication documentation, resident was not diagnosed with a staph infection.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20220503151514
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VINE RIDGE AT CLOVERDALE
FACILITY NUMBER: 496803825
VISIT DATE: 06/23/2022
NARRATIVE
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Continued from LIC9099

Facility failed to need resident's care needs – Complaint alleges that resident has had weeping wounds on their legs for four months. Interviews indicated that resident, R1 has had a rash on their legs for 2-3 months. Correspondence between the facility and R1’s physician dated 2/17/2022 indicates that the facility notified the physician that resident was showing signs of blisters on their legs and noted R1’s history of leg swelling and dryness. Per interview, R1’s physician arrived at facility to conduct an exam and complete the Physician’s Report. Per file review, R1's physician completed an LIC602 Physician’s Report on 2/17/2022. Physician responded to facility’s correspondence citing what they observed and provided new orders for resident which included a prescription and compression socks. Review of the Electronic Medication Administration Record indicated that R1 took the prescribed medication for 10 days. Per interview, the compression socks were not received from the doctor while another interviewee indicated that the resident refused to wear the socks. Review of file revealed that facility sent out communication to doctor again on 4/5/2022 following an attempted hospital visit where resident was sent back from the hospital without treatment of their legs due to resident being non-compliant at the hospital. Resident was then sent back to the hospital on 5/1/2022 where they treated and prescribed medication. Per LPA follow-up today, R1's skin issue improved following the 5/1/2022 hospital visit where resident was prescribed medication.

A finding that the complaint allegations Facility retained a resident with a prohibited condition and Facility failed to meet resident's care needs was unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegations occurred.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20220503151514
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINE RIDGE AT CLOVERDALE
FACILITY NUMBER: 496803825
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
07/01/2022
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy
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Administrator agrees to conduct an in-service for all staff regarding regulation 87468.2 and will submit a sign-in sheet showing staff have been trained to CCL by POC due date, 7/1/2022.
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in accommodations... This requirement has not been met as evidenced by interviews confirming that a resident in memory care goes into other resident's rooms and goes through their personal items. This is a potential risk to the personal rights of residents in care.
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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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220503151514
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VINE RIDGE AT CLOVERDALE
FACILITY NUMBER: 496803825
VISIT DATE: 06/23/2022
NARRATIVE
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Continued from LIC9099

The allegation that facility failed to ensure resident's personal rights is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5