496804113-5-20-2025-21-AS-BMOS-DJZPMD-20250728112610

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804113
Report Date: 05/20/2025
Date Signed: 05/20/2025 04:30:20 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
03/06/2025 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20250306141449

FACILITY NAME:	FOUNTAINGROVE LODGE		FACILITY NUMBER:	496804113
ADMINISTRATOR:	LEONE, MEGAN E.		FACILITY TYPE:	741
ADDRESS:	4210 THOMAS LAKE HARRIS DRIVE		TELEPHONE:	(707) 576-1101
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	173	CENSUS:	DATE:	05/20/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Megan Leone-Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff is restricting resident's ability to have visitation

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 5/20/25 at approximately 9:45am, and met with Administrator Megan Leone.

Reporting party alleges that “staff is restricting resident's ability to have visitation”. LPA reviewed resident’s (R1) records. LPA reviewed the signed admission agreement, including the facility’s “house rules” in the agreement. LPA reviewed all admission documents, including medical assessment, resident care plan, and medication list/Dr’s Orders.

LPA reviewed facility policy and procedures regarding resident visitors/guests, including by former staff; LPA reviewed facility policy and procedures on residents/responsible parties hiring a resident companion.

Reviewed policy and procedures of staff accepting gifts and gratuities. The LPA obtained copies of requested records.
Continued on LIC9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250306141449

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: FOUNTAINGROVE LODGE	FACILITY NUMBER: 496804113
	VISIT DATE: 05/20/2025

NARRATIVE

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The LPA conducted interviews with staff, and other related parties. Per review of records, observations, and information obtained, the investigation revealed there was no information obtained that the facility was restricting resident’s ability to have visitation. There was information reviewed and obtained of communication from administration staff to a current staff (S2) (at the time), of facility employee handbook policy and procedures. The communication documentation stated in writing the responsibility of the facility staff to ensure compliance with the employee handbook and facility policies/procedures regarding employment, and any interactions with residents of the community.

The documentation reviewed referred to policy and procedures of a former staff regarding “community visits” when employment ends, interactions with staff during their visits, and requirements of a “resident companion” that need to be complied with, if they are a resident companion. Per interviews, former staff does come into the community to visit with R1.

There was differing information obtained from parties interviewed; There was no information obtained in the investigation to support a violation had occurred. Per the investigation regarding the allegation that “staff is restricting resident's ability to have visitation” is unsubstantiated.

Based on LPA interviews, record/document reviews, and related information obtained during the investigation, the allegation is Unsubstantiated, meaning that 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.

No deficiencies cited.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC9099 (FAS) - (06/04)

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