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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804113
Report Date: 02/27/2024
Date Signed: 02/27/2024 11:44:34 AM


Document Has Been Signed on 02/27/2024 11:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:FOUNTAINGROVE LODGEFACILITY NUMBER:
496804113
ADMINISTRATOR:MOONEY, SHAWNFACILITY TYPE:
741
ADDRESS:4210 THOMAS LAKE HARRIS DRIVETELEPHONE:
(707) 576-1101
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:173CENSUS: 101DATE:
02/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Megan Leone-Executive DirectorTIME COMPLETED:
11:55 AM
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Licensing Prigram Analyst (LPA) Alviso conducted a case management incident inspection, on 2/27/24 at approximately 9:10am, and met with Megan Leone, Executive Director (ED).

The case management is being conducted to review and obtain additional information, on a resident incident that was recently reported to the Department. The LPA reviewed the incident report, death report, and resident records, including medical documentation.

Per review of records, information obtained, and interviews with staff, R1 was identified as independent, and was able to access the community on their own. Per review of today's records and interviews, staff addressed the incident as needed, when it occurred.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
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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