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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804113
Report Date: 06/04/2025
Date Signed: 06/04/2025 03:57:44 PM

Document Has Been Signed on 06/04/2025 03:57 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FOUNTAINGROVE LODGEFACILITY NUMBER:
496804113
ADMINISTRATOR/
DIRECTOR:		LEONE, MEGAN E.FACILITY TYPE:
741
ADDRESS:4210 THOMAS LAKE HARRIS DRIVETELEPHONE:
(707) 576-1101
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 173CENSUS: 133DATE:
06/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Megan Leone-Administrator/Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct an Annual Required - 1 Year inspection, at approximately 9:45am on 6/4/25, and met with Administrator Megan Leone. LPA toured the facility, assisted living (AL) main building, and the memory care (MC) building, with administration staff, Megan Leone, Administrator/ED, Joel Gonzalez, Business Office Director (BOD), and Michelle Simpson, Health Services Director.

Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has a plan of operation for dementia care. The facility has a hospice waiver approval for ten (10) residents.
Fire clearance is approved for one hundred and seventy-three non-ambulatory, of which 16 may be bedridden. Capacity breakdown as follows: AL main building, and the five (5) bungalows are cleared for one hundred and forty (140) non-ambulatory, of which six (6) may be bedridden, the MC building is cleared for thirty-three (33) non-ambulatory, of which ten (10) may be bedridden; Total license capacity is one hundred and seventy-three (173) . The delayed egress is approved, per fire clearance.
Per review of the emergency disaster drills binder, the facility is completing quarterly drills as required.All exits were clear and unobstructed. Facility fire extinguishers were serviced and tagged as required. All stairwells, four (4) in AL, and one (1) in MC, all had the required emergency evacuation chair, including all had instructions on use posted up.

LPA reviewed ten (10) resident files, including medications, and medication records were reviewed.
LPA reviewed ten (10) staff files. All staff had required criminal record clearance. All staff have required training.

Facility has sufficient supply of perishable and non-perishable food. Freezer and refrigerator was observed to be orderly, and within required temperature (s).
Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/04/2025
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Facility had sufficient supply of the following: cleaners/disinfectants, paper products, soaps, sanitizer, and personal protective equipment (PPE). Facility had sufficient lighting throughout the facility, in observed common areas, hallways, and bathrooms. Facility was at a comfortable temperature during the inspection. Facility had emergency supplies as required; Facility had supplies to meet the requirements of "72 hours- Shelter in Place".

LPA is requesting the following documents be updated and submitted by 7/4/25:
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required -if no changes, submit the last page with date/signature of review)
Infection Control Plan (ensure to review and update as needed/required -if no changes, submit the last page with date/signature of review)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed
Copy of Current Liability Insurance
Copy of Administrator Certificate
Updated LIC500 Personnel Report
LIC308 - Designation of Administrator Responsibility

The following observed deficiencies will be cited:
LPA observed with the administration staff during the memory care tour that a resident's, R1, room smelled strongly of urine, observing the room to be in need of a deep cleaning to ensure "facility is free from incontinent odors" as required by regulation; Managed Incontinence 87625(b)(3)- Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence, see LIC809D.

LPA observed with the administration staff during the memory care tour that resident’s, R1, room had blinds hanging on their windows that were broken and some pieces missing; LPA observed the blinds hanging on the window in joint/shared private sitting area right outside of R1's room to be in the same condition as their room blinds. 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 LIC809D.

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.

Exit interview conducted with the Administrator/ED Megan Leone.
Appeal Rights Provided to the Administrator/ED.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2025 03:57 PM - It Cannot Be Edited


Created By: Dina Alviso On 06/04/2025 at 02:45 PM
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: FOUNTAINGROVE LODGE
FACILITY NUMBER: 496804113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed with the administration staff during the memory care tour that a resident's, R1, room smelled strongly of urine, observing the room to be in need of a deep cleaning to ensure "facility is free from incontinent odors" as required by regulation], the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2025
Plan of Correction
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Licensee/Administrator to ensure the resident's, R1's, room is cleaned and free from urine odors. Ensure the facility is free from incontinent urine odors and as required by regulation. Ensure resident's care plan addresses the needs to meet all R1's managed incontinence care, including incontinent odors. Submit plan of correction, and include a maintainence plan for R1's room regarding incontinent odors. POC due 6/16/25.
Type B
Section Cited
CCR
87303(a)
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 is not met as evidenced by:
Deficient Practice Statement
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LPA observed with the administration staff during the memory care tour that resident’s, R1, room had blinds hanging on their windows that were broken and some pieces missing; LPA observed the blinds hanging on the window in joint/shared private sitting area right outside of R1's room to be in the same condition as their room blinds], the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2025
Plan of Correction
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Licensee/Administrator to ensure the facility is in good repair at all times; Please submit plan of correction in replacing the blinds in R1's room and sitting area and/or repairing the blinds. Please submit how the resident's blinds were corrected, repaired and/or replaced. Submit POC by 6/16/25.
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:
Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
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