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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 08/19/2022
Date Signed: 08/19/2022 05:44:50 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
08/16/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220816100641
FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:LANHAM, RACHAELFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:58CENSUS: 25DATE:
08/19/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Rachael LanhamTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility did not follow their Covid Mitigation Plan
Facility is not safe, sanitary and in good repair

INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrived unannounced to conduct an investigation regarding the above mentioned complaint allegations and met with Administrator, Rachael Lanham. Licensee, Larona Farnum was available by phone.

LPA made observations, conducted interviews and reviewed files.

Facility did not follow their Covid Mitigation Plan - Complaint alleges that facility had Covid + residents and staff in July 2022 and did not notify residents and their responsible parties. LPA confirmed through interviews that two residents and three staff tested positive for Covid in July 2022 and not all responsible parties or the Department of Public Health were notified. Interview also confirmed that facility did not test all staff and residents once there were confirmed positive staff and residents in the facility. Review of Special Incident Reports confirm that Community Care Licensing was not notified either.

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

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
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
Control Number 21-AS-20220816100641
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: 08/19/2022
NARRATIVE
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Continued from LIC9099

When LPA arrived at the facility, three staff did not have masks on; one in the reception area and two in the dining room, one of which was less than six feet from an unmasked resident. Facility's Covid Mitigation Plan says, in part, the following: (Pg 7) Facilities with Covid - "If an active case of COVID-19 is identified in the community (staff or resident), all staff and residenst are tested every 7 days, or as directed by the county health department"; (Pg 13) "All facility staff are wearing a face covering while on the premises"; (Pg 15) "Our Executive Director/Administrator takes primary responsibility for communicating with all relevant parties regarding COVID-19. Communication is done via phone calls, email, written letters, and updates to our website." Evidence shows that multiple areas of the Covid Mitigation Plan are not being followed.

Facility is not safe, sanitary and in good repair - Complaint alleges that the delayed egress door into Memory Care is not working. Also, that the live-in staff do not pick up their dog's feces and that there are urine stains on the carpet. During inspection LPA conducted a walk through and observed the following: LPA did not see feces or stains that were necessarily urine. The facility did not smell like feces or urine. LPA did confirm through observation that the delayed egress door into Memory Care is not working. It is not locking and the alarm does not sound. Administrator did show LPA that the notification to staff's phone showing the door was open does work so staff are notified in that way. LPA walked into the Memory Care outdoor area and observed that there are three gates that leave this area. One is locked and two opened but did not sound an alarm. The delayed egress door that goes into this area from the Memory Care living room is not locked or alarmed and once someone goes through it into the outdoor area, the door locks behind them and someone from inside the building must let them in. This does not allow for residents to wander freely inside and outside, which is a requirement of regulation. Inside the facility, LPA observed two discolored areas on the ceiling near the Assisted Living common area. Staff explained that the spots were due to plumbing in the ceiling that was leaking. One spot was brown and black and approximately 10 inches long. The carpet below the spot was not discolored or wet and it did not appear that water was leaking onto the carpet.

The allegations that Facility did not follow their Covid Mitigation Plan and Facility is not safe, sanitary and in good repair 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: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 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
08/16/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220816100641

FACILITY NAME:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:LANHAM, RACHAELFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:58CENSUS: 25DATE:
08/19/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Rachael LanhamTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility failed to ensure that individuals have proper fingerprint clearance and association
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrived unannounced to conduct an investigation regarding the above mentioned complaint allegations and met with Administrator, Rachael Lanham. Licensee, Larona Farnum was available by phone. LPA made observations, conducted interviews and reviewed files.

Facility failed to ensure that individuals have proper fingerprint clearance and association - Complaint alleges that a live-in staff has a significant other who is not an employee but who is staying at the facility and is around residents. Interview with involved staff confirmed that they're significant other does visit on the weekends and stays the night. LPA confirmed that the individual is not cleared to work or reside in the facility. Interviews indicated that individual is not providing care or supervision. LPA could not confirm that the individual has been left alone with residents or that they are residing in the facility.

A finding that the complaint allegation facility failed to ensure that individuals have proper fingerprint clearance and association was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220816100641
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: 08/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement has not been met based on interviews and LPA observation showing
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Facility representative agrees to submit dates of when repairs are planned for by POC due date, 8/20//2022.

Facility also agrees to notify LPA once repairs are completed.
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that the delayed egress doors in Memory Care are not functioning correctly and there is visible evidence of a plumbing leak on the cealing in Assisted Living. This is an immediate risk to the health asnd safety of residents in care.
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Type B
08/22/2022
Section Cited
CCR
87705(I)(5)
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87705 Care of Persons with Dementia (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (5) Interior and exterior space shall be available on the facility premises to permit residents with dementia to wander freely and safely. This requirement has not been met based on LPA observation
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Facility representative agrees to submit date of when door will be repaired to allow for residents to wander freely by POC due date, 8/22//2022.

Facility also agrees to notify LPA once repair is completed.
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showing that the door that goes into the outdoor area automatically locks which does not allow resident to wander freely. 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: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5