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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286802049
Report Date: 06/02/2023
Date Signed: 06/02/2023 11:03:54 AM

Substantiated


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
04/18/2023 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20230418084833
FACILITY NAME:VINTAGE HOUSEFACILITY NUMBER:
286802049
ADMINISTRATOR:ROA, FRANCISCOFACILITY TYPE:
740
ADDRESS:2541 VINTAGE STREETTELEPHONE:
(707) 265-8652
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 3DATE:
06/02/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Caregiver, Renee Johnson BernabeTIME COMPLETED:
11:13 AM
ALLEGATION(S):
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Facility staff refused to take resident back after a hospitalization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Bertozzi arrived unnaounced to deliver findings regarding the above complaint allegation and met with Caregiver, Renee Johnson Bernabe. Licensee/Administrator was available by phone.

Complaint alleges that resident was diagnosed with Covid while at the hospital and facility refused to bring resident back to the facility. Per interviews, the hospital initially agreed to keep the resident for twenty days but later agreed to isolate the resident in the hospital for ten days. Interviews revealed that Licensee refused to bring resident back until resident tested negative on a Covid test. Per Licensee, the resident was in a shared room and they were unable to isolate them but other interviews revealed that facility did have a vacant room that could used as an isolation room.

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

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
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 3
Control Number 21-AS-20230418084833
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: VINTAGE HOUSE
FACILITY NUMBER: 286802049
VISIT DATE: 06/02/2023
NARRATIVE
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Continued from LIC9099

The allegation that Facility staff refused to take resident back after a hospitalization 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 Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20230418084833
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: VINTAGE HOUSE
FACILITY NUMBER: 286802049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2023
Section Cited
CCR
87464(f)(1)
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(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance
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LPA discussed with Licensee that facility may not refuse bringing a resident without a prohibited health condition back to the facility once discharged from the hospital. Deficiency is cleared.
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with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.., Based on interviews, Licensee did not meet requirement by not accepting a resident back from the hospital. This is an immediate risk to personal rights.
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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 Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3