496803825-10-14-2021-21-AS-HDBI-C7ZVJ4-20211021162808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803825
Report Date: 10/13/2021
Date Signed: 10/14/2021 11:26:49 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/28/2021 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20210628131611

FACILITY NAME:	VINE RIDGE AT CLOVERDALE		FACILITY NUMBER:	496803825
ADMINISTRATOR:	UBALLEZ, DAVID		FACILITY TYPE:	740
ADDRESS:	247 TREADWAY DRIVE		TELEPHONE:	(707) 791-4787
CITY:	CLOVERDALE	STATE: CA	ZIP CODE:	95425
CAPACITY:	58	CENSUS: 21	DATE:	10/13/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	David Uballez		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility staff do not keep the facility clean
Facility is not following their Mitigation Plan
Facility staff are not keeping accurate medication logs
Facility staff are not dispensing medications as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with Administrator and discussed the department's findings. During the course of this investigation statements were taken from staff; residents; witnesses. In addition, six unannounced site visited were made to the facility and photographs were taken of various areas. Numerous records and documents were obtained and reviewed. The following determinations have been made: Staff reports and site visits made support that the mitigation plan for the facility is being followed; Facility observed to be clean at all unannounced site visits; reviews of Medication Administration Record and other logs as well as statements made by staff and administrator indicate procedures for medication administration and record keeping is in line with Title Twenty-Two regulations. Although the allegations may be true, based upon the records and statements, as well as observations, there is not a preponderance of evidence to support the allegations. Therefore, the allegations are UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

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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