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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 08/30/2022
Date Signed: 08/30/2022 02:06:53 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:
08/30/2022
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Administrator, Rachael LanhamTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Insufficient Staffing
Resident needs are not being met
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegations and met with Administrator, Rachael Lanham.

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

Insufficient Staffing - Complaint alleges that facility has insufficient staffing to meet the needs of the residents. Review of the LIC500 showed that at least one Sunday had one caregiver and one Medication Technician scheduled for Memory Care and Assisted Living. Per interviews and review of schedules, staffing shortages have resulted in the Administrator having to cover caregiving duties, staff being scheduled for double shifts and some shifts having one caregiver and one Medication Technician responsible for activities of daily living for more than 20 residents which includes Memory Care residents who require more supervision.

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

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
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 4
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: 08/30/2022
NARRATIVE
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Continued from LIC9099

Resident Needs are not being met - Complaint alleges that resident needs are not being met including but not limited to a resident receiving a cold meal after staff forgot to deliver their dinner and a resident not receiving assistance with their activities of daily living. Per complaint, a resident was given a cold omelette after staff forgot to bring them their dinner. Interviews indicated that staff did forget to bring the resident dinner but denies giving them a cold omelette stating that they did heat it up. LPA observed around 2:00pm on August 19, 2022 that a resident's lunch was sitting on their counter in their apartment. Per LPA conversation with resident, they were unaware that their lunch had been dropped off. Discussion with kitchen staff indicated that they were unaware that resident needed to be notified that their meal was there. Interviews and review of resident care plan revealed that resident receives assistance with dressing, putting on and taking off their hearing aids and getting assistance with their morning and night routines but per interviews, this does not always happen resulting in hearing aids not being charged, resident sleeping in their compression socks and resident sleeping in their chair instead of in bed. Interview and review of care plan indicated that resident also needs assistance with coming down to meals. Per interviews, caregivers do not always bring resident down. Some interviews indicate that resident initially refuses to come down to meals but can usually be persuaded.

The allegations that facility has Insufficient Staffing and Resident needs are not being met 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: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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:
08/30/2022
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Administrator, Rachael LanhamTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Administrator Qualifications
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegation and met with Administrator, Rachael Lanham.

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

Complaint alleges that Administrator does not have the qualifications to be the Administrator. LPA review of Administrator qualifications indicate that they are qualified per regulation. Investigation has revealed that Administrator is required to provide caregiving duties due to insufficient staffing though it is not clear to what extent it has resulted in the Administrator not being able to fulfill their administrative duties.

A finding that the complaint allegation Administrator Qualifications 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: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
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 4
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: 08/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide services necessary to meet resident needs. In facilities licensed for 16 or more, sufficient support staff shall be employed to ensure provision of personal assistance & care as required.. Additional staff shall be employed
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Per discussion with Licensee, they are actively recruiting, hiring and training staff. Facility has brought staff from their other facilities to cover shifts. Facility to provide, in writing, their plan to ensure staffing while new staff are being trained by POC due date, 8/31/22.

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as necessary to perform office work, cooking, house cleaning, laundering, & maintenance of buildings, equipment and grounds. This requirement was not met based on: Per interviews & document review, Licensee did not ensure sufficient staffing. This is an immediate risk to the health and safety of residents in care.
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Type A
08/31/2022
Section Cited
CCR
87464(f)(4)
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*Amended*
87464 Basic Services (f) Basic services shall at a minimum include:...(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications
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Licensee agrees to submit an updated policy outlining how all staff including but not limited to kitchen staff, caregivers, Medication Technicians and Activity Directors will be notified of resident's needs and how facility will ensure the needs are met by POC due date, 8/312022.
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... This requirement was not met based on: Per interviews & document review, Licensee did not ensure that resident's needs were being met. This is an immediate risk to the health and safety 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: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4