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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803825
Report Date: 08/30/2022
Date Signed: 08/30/2022 01:57:28 PM

Document Has Been Signed on 08/30/2022 01:57 PM - 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:VINE RIDGE AT CLOVERDALEFACILITY NUMBER:
496803825
ADMINISTRATOR:LANHAM, RACHAELFACILITY TYPE:
740
ADDRESS:247 TREADWAY DRIVETELEPHONE:
(707) 791-4787
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 58CENSUS: 25DATE:
08/30/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Administrator, Rachael LanhamTIME COMPLETED:
01:57 PM
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Licensing Program Analyst Willis arrived unannounced to conduct a Plan of Correction visit and met with Administrator, Rachael Lanham.

Based on LPA's observation and review of invoices, facility has corrected the deficiencies that were cited on August 19, 2022. Facility has repaired the delayed egress door that goes into Memory Care and has corrected the exterior door so that it does not automatically lock which now allows dementia residents to wander freely. LPA has requested an updated fire clearance regarding the gates that leave the outdoor area and the facility is actively working with the fire department. The facility has had the pipe fixed that was leaking and causing discoloration on the ceiling in Assisted Living.

No deficiencies cited.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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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