Vineyard Place

Allegation investigated: Staff are not following resident's advanced directives regarding who makes decisions for resident's care Staff do not meet resident's toileting needs Staff do not keep the facility free from odor

Licensing Program Analysts (LPA) Seo Jeon and Kyle Wellington conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Angela Jackson, Community Relations Director. The Department investigation involved interviews with staff and residents and review of records. On 07-18-2022, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged staff are not following resident’s advanced directives regarding who makes decisions for resident’s care. Information received indicated spouse of Resident #1 (R1) continued to make decisions about R1’s care despite R1’s spouse’s declining cognitive condition. LPA’s record review revealed R1 had been admitted and receiving hospice care since December 2021. LPA’s review of R1’s advance healthcare directives revealed R1’s spouse was the designated agent to make healthcare decisions. Continued on LIC9099-C.... Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 9, 2026 · control 18-AS-20220718161418

Allegation investigated: Resident developed sepsis while in care Staff served cold food to resident Resident is not served an adequate amount of food Facility is unsanitary Facility not allowing resident to receive phone calls

Licensing Program Analysts (LPA) Seo Jeon and Kyle Wellington conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Angela Jackson, Community Relations Director. The Department investigation involved interviews with staff and residents and review of records. On 07-18-2022, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that resident developed sepsis while in care. LPA’s review of records revealed Resident #1 (R1) had been admitted to the facility under dementia care plan as of 12-01-2021 and passed away on 08-28-2022. R1’s certain health conditions led to infection, and R1 was sent to a hospital on 06-17-2022. R1 was discharged on 06-26-2022 with diagnosis of sepsis. R1 developed sepsis while in care, but LPA’s review of R1’s discharge report did not reveal any information to indicate what caused R1 developing sepsis. Continued on LIC9099-C..... Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 9, 2026 · control 18-AS-20220718100037

Allegation investigated: Staff not abiding by resident's care plan Staff restricting visitation to residents Staff over-medicating resident

Licensing Program Analysts (LPA) Seo Jeon and Kyle Wellington conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met Angela Jackson, Community Relations Director. The Department investigation involved interviews with staff and residents and review of records. On July 18, 2022, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that staff are not following resident’s care plan. Specifically, the concern was that Resident #1 (R1) was not receiving care in accordance with their care plan. LPA’s file review revealed that R1 was non-ambulatory who required a Hoyer lift for transferring. LPA conducted an interview with R1 who stated that they had received all the care and assistance from the facility staff. Continued on LIC9099-C.... Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 9, 2026 · control 18-AS-20220718093804

Allegation investigated: Facility is not allowing resident to have visitors Facility does not have sufficient staff to meet resident's needs

Licensing Program Analysts (LPA) Seo Jeon and Kyle Wellington conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Angela Jackson, Community Relations Director. The Department investigation involved interviews with staff and residents and review of records. On 07-14-2022, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged the facility is not allowing resident to have visitors. Information received indicated staff allegedly denied visitors when there were two (2) or more Covid-19 cases in the facility. LPA’s record review revealed that Resident #1 (R1) was admitted in December 2021 and began receiving hospice care in June 2022. LPA’s interview with the Administrator revealed staff have never denied any visitation to any individuals, provided visitors completed the required symptoms questionnaire. Continued on LIC9099-C.... Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 9, 2026 · control 18-AS-20220714165026

Allegation investigated: Staff neglect resulted in a resident sustaining a pressure injury.

Licensing Program Analyst (LPA) Javina George conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, the LPA met with Angela Jackson, Community Relations Director and explained the reason of the visit. On 01/17/2024, the Riverside Adult and Senior Care Regional Office (RO) received a complaint report regarding neglect resulted in a resident sustaining a pressure injury. It was alleged that on 10/12/2023, Resident #1 (R1) was bedridden and observed to have maggots on R1’s pressure injury. The Department’s investigation revealed on 05/06/2023, R1 was admitted back to the facility from the hospital with a Stage II pressure injury to coccyx and was placed on hospice due to R1’s inability to thrive. R1 began receiving wound care treatments and additional services under a hospice agency. Facility staff were directed to reposition R1 every 2 hours and provide incontinent care every 2 hours or more Unfoundedthe state’s words, verbatim · CDSS document, Sep 18, 2025 · control 18-AS-20240117100409

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident's medical needs are not being met.

On March 28, 2024, Licensing Program Analyst (LPA), Venus Mixson conducted a visit and met with the Clinical Services Director, Ivy. The visit was conducted to provide the findings for the investigation pertaining to the listed allegation. The investigation consisted of staff and resident interviews, witness interviews, record reviews, and observations. On August 03, 2022, Community Care Licensing received a complaint alleging that a resident's medical needs are not being met. It was reported that Resident Number 1 (R1), has not seen a physician since the initial hospitalization. It was also alleged that the resident has not received medical attention or seen a physician. Regarding the allegation resident's medical needs are not being met, it was advised that the resident receives Hospice services and is seen by a Hospice Nurse several times a week. Additionally, it was advised that R1 is on Hospice with West Coast Hospice and the attending physician is responsible for seeing the residthe state’s words, verbatim · CDSS document, Mar 28, 2024 · control 18-AS-20220803101043

Allegation investigated: Facility staff are not properly trained on how to transfer residents Facility is in disrepair Facility is unsanitary Facility is malodorous

Licensing Program Analyst (LPA), Jacqueline Shaw Ross made an unannounced visit to deliver findings for the allegations noted above. LPA met with Nieves Villapando, Clinical Service Director, and explained the purpose of the visit and the elements of the allegations. The investigation consisted of observations, interviews, and records review. On 10/17/2023, Community Care Licensing received a complaint allegation that facility staff are not properly trained on how to transfer residents and that the facility is in disrepair, unsanitary, and malodorous. In regards to the allegation that staff are not properly trained on how to transfer residents, it was reported that staff is not trained to properly lift (transfer) resident from wheelchair to toilet or showering. Interviews obtained stated that staff is trained at the start of hire and annually. LPA reviewed training documents that indicate dates and types of training. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 11, 2024 · control 18-AS-20231017142010

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.