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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804324
Report Date: 03/02/2026
Date Signed: 03/02/2026 09:42:44 AM

Document Has Been Signed on 03/02/2026 09:42 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:RESERVE AT FOUNTAINGROVE MEMORY CARE, THEFACILITY NUMBER:
496804324
ADMINISTRATOR/
DIRECTOR:		ORDING, KELLYFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 64CENSUS: 25DATE:
03/02/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:46 AM
MET WITH:Edgar Bravo (Dining Services Director)TIME VISIT/
INSPECTION COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management - incident visit and met with Edgar Bravo, Dining Services Director. The purpose of this case management inspection is to follow up on a self-report incident report submit to Community Care Licensing (CCL) on 02/17/2026.

CCL received a self-report incident report on 02/17/2026 reporting an incident that occurred on 02/10/2026 at approximately 6am. Resident (R1) left their apartment using their walker, R1 exited through front egress doors into lobby, then exited through front lobby door, until they were found on the sidewalk in front of the community by a member of staff within 20 minutes of leaving. R1 said that they were waiting for a ride. R1 was escorted back into the community. R1 was assessed by staff and there were no injuries. During today’s visit, LPA learned that the incident happened while the staff was doing the cross over shift and there was no staff supervising the residents. Per Dining Services Director, the facility implemented a preventive measure to maintain at least one staff inside memory care unit during the shift change meeting. LPA also reviewed R1’s physician report (LIC 602) dated 3/24/2019, care plan indicates that R1 has been added to the monitor alert chart, in-service training records confirmed that staff held a training session on 2/18/26 including elopement drill documentation tool, which is included to the facility elopement procedures. Alarm book is documenting inspection dates and times when the checks are been performed. Facility Policies and Procedures regarding AWOL/Elopement were not followed.

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.

Exit interview was conducted with Dining Service Director and copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/02/2026 09:42 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/02/2026 at 09:21 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: RESERVE AT FOUNTAINGROVE MEMORY CARE, THE
FACILITY NUMBER: 496804324

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2026
Section Cited
CCR
87705(e)(7)

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87705(e)(7) Care of Persons with Dementia- Licensees that use delayed egress devices on exterior doors...: Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents,, including staff needed to escort residents who need supervision to leave the facility. This requirement was not met as evidenced by:
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The facility provided to LPA an in-service training record dated 2/18/26 with staff, also they have implemented door check monitoring log and R1 was added to the monitor alerting chart to prevent that this type of incident happens again a staff will be designated to maintain at the memory care unit during the change of shift meeting. Deficiency cleared.
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Based on LPA's records review and interviews with Dining Service Director, the facility failed to prevent R1 who AWOL the memory care unit from the egress exit, pressing on it for time required will release it, alarm sounded, but staff was having cross over meeting, and they were not alerted until they found R1 in the parking lot, which is a potential risk to the health & 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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


LIC809 (FAS) - (06/04)
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