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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804113
Report Date: 08/07/2024
Date Signed: 08/07/2024 03:30:12 PM

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
07/31/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240731131411
FACILITY NAME:FOUNTAINGROVE LODGEFACILITY NUMBER:
496804113
ADMINISTRATOR:LEONE, MEGAN E.FACILITY TYPE:
741
ADDRESS:4210 THOMAS LAKE HARRIS DRIVETELEPHONE:
(707) 576-1101
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:173CENSUS: DATE:
08/07/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Joel Gonzalez- Business Office Manager TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Apartment unit has another water leak, not repaired, the unit has had many water leaks in the last few months
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 8/7/2024 at approximately 11:00am, and met with Joel Gonzalez, Business Office Director, and Health Services Director, Michelle Simpson. Administrator would be arriving to the facilty later this morning to meet with the LPA.

LPA reviewed records, obtained copies of documents, interviewed staff, and other related parties.The LPA reviewed the following facility records: records on the leaks in the apartment unit, of R1 & R2, repair receipts of 2024 on leaks in the unit, and report on testing the units water damaged areas for mold, inspected by Air Environmental. LPA reviewed plans on facility obtaining a new dishwasher, and the kitchen floor being resealed; The water has been leaking from the kitchen to the apartment unit below. The apartment unit has had leaks on 3/13/24, 4/18/24, 6/15/24, and on 7/27/24. All leaks were repaired, except the leak of 7/27/24 as this will be repaired once the kitchen repairs are completed. LPA reviewed records of options offerred to R1 & R2 regarding their apartment unit, they can move into a comparable unit if available, and they may stay in a guest suite and/or a hotel during apartment unit repairs. These offers have been declined in the past, but are offerred during the repair time for the 7/27/24 leak.
Per review of financial account records, there have been rent credits provided for each time leaks occurred resulting in needed repairs. Per interviews, the kitchen has had past plumbing issues, drain issues, and most recently the leaking of the dishwasher. Some of residents' belongings were stored by the facility for them until repairs were completed.
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
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-20240731131411
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: 08/07/2024
NARRATIVE
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The investigation revealed that R1 & R2's unit has water damage from a leak that occurred 7/27/24, and can't be repaired until other work is completed in the kitchen area, as stated above. Residents, R1 & R2, have had numerous leaks occur in the past, and this year there have been four leaks, see dates above. Per interviews, staff have observed and known of past water leaks in the facility kitchen, including the latest from the dishwasher.

Per review of records, conducted interviews with staff and other related parties, information obtained, the allegation of "Apartment unit has another water leak, it's not repaired, the unit has had many water leaks in the last few months" is substantiated.

The following deficiency will be cited, 87303(a) Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors., see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.

Appeal Rights Given.
Exit interview conducted with the Administrator Megan Leone.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240731131411
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/19/2024
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Licensee/Administrator to submit plan of repairing the water damage in R1 &R2's unit, and plan on repairs to the kitchen, the dishwasher and resealing of the floor. Submit plans of corrections, and estimated start and completion dates. POC due 8/19/24
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The investigation revealed that R1 & R2's unit has water damage from a leak that occurred 7/27/24, and can't be repaired until other work is completed in the kitchen area, as stated above. Residents, unit has had numerous leaks occur in the past, and this year there have been four (4) leaks, see dates above. Per interviews, staff have observed and known of past water leaks in the facility kitchen, including the latest from the dishwasher. This is a risk to residents personal rights and/or health & safety.
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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: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC9099 (FAS) - (06/04)
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