Vineyard At Fountaingrove, The is a residential care home for the elderly (RCFE) in Santa Rosa, Sonoma County, California — state license #496803698, with a licensed capacity of 64, listed as closed, change of ownership in the CDSS record we retrieved August 2, 2026. It does not appear on the DHCS Assisted Living Waiver participant list checked August 9, 2026 — that list covers the state waiver only, not a home's own payment arrangements. California has 74 dated inspection and complaint documents on file for this home going back to 2021, the most recent dated October 2, 2025 — published below in full, verbatim and unscored.

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157 homes in view

Vineyard At Fountaingrove, The

The state record lists this licence as “Closed, Change of Ownership”. A closed licence cannot admit residents. We keep closed licences published because “is this place licensed?” deserves an honest answer.

The state also licenses a home at this address today: Reserve At Fountaingrove Memory Care T · licence #496804324

No photo on file yet

No photo of this home is on file — we show real, attributed images only, never a stock photo of someone else’s building.

Residential care home for the elderly (RCFE) · Large community, 64 residents · Santa Rosa, CA · Sonoma County
Closed in state recordMemory careHospiceBedriddenWheelchair not on file
No openings reportedBeds change hands in days · we confirm by phone before any referral
License #496803698, held since 2017 · read from the California state record on August 2, 2026 ·See on State Site →
200 Fountaingrove Pkwy · Santa Rosa, Sonoma County
Phone
(707) 544-4909
from the state licensing roster · August 2, 2026
No Google listing is on file for this home.
Website
None on file
Many small homes have no website — that says nothing about the care inside.
Contact facts come from the state roster, a county Area Agency on Aging roster, the home’s Google listing, or the operator — each labelled, never blended. Operators: add or correct yours, free →

Wheelchair / non-ambulatoryNot on file — ask the home
Dementia / memory careVerified in record
Hospice careVerified in record
Bedridden careApproved for 12 residents

“Not on file” is not a no — approvals can be bed- or room-specific, so confirm current scope with the home on a tour. Where a number is shown it is the state’s own wording for how many residents the approval covers, not how many places are open today; where none is shown, the record simply does not state one.

Specific medical needs — insulin, oxygen, a catheter, an ostomy — aren’t in the state license record; ask the home directly. A feeding tube, tracheostomy, or advanced wound care usually needs skilled nursing →

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What the state record says, word for word
64 NONABMULATORY, OF WHICH 12 MAY BE BEDRIDDEN. HOSPICE WAIVER GRANTED FOR 10. NEW MGMT CO. ONELIFE SENIOR LIVING LLC, FM SANTA ROSA INVESTORS, EFFECTIVE 2/20/25.State service designation983 - RCFE / DEMENTIAthe CDSS license record, verbatim · checked August 2, 2026

“RCFE / Dementia” is the state’s designation for a home with an approved Dementia Care Plan of Operation — it’s recorded separately from the comments above, which is why the memory-care approval may not appear in that text.

Since 2021, the state has visited this home 87 times and filed 74 documents. The most recent is a facility evaluation report, dated October 2, 2025.

Most recent state visit
October 2, 2025
Occupancy at the January 9, 2025 visit
26 of 64 beds

The state's published file for this home includes 25 documents with transcribed findings, dated July 23, 2021 to January 9, 2025. 25 of the 25 carry the state's recorded outcome word: “Substantiated” (15), “Unsubstantiated” (10). 25 include the transcribed allegation the state investigated, word for word.

Summary composed by computer from the 25 documents below — every count derives from them, and the documents themselves are the state's records, verbatim. We never grade, score, or color a record.

What the state’s words mean
Substantiatedthe state found the allegation more likely true than notUnsubstantiatedinvestigated, but couldn’t be confirmed either way — not a finding of wrongdoingUnfoundedthe state concluded it was false or couldn’t have happenedType A citationthe most serious: an immediate health-or-safety risk, usually fixed on the spot or on a short deadlineType B citationless serious, with a deadline to fix
The last 36 months — 55 of 74 documentsFull record on the state’s site →
202512 state visits · 21 documents
Oct 2, 2025Facility evaluation reportReport on file

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

Sep 9, 2025Facility evaluation reportReport on file

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

Aug 28, 2025Complaint investigation reportReport on file

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

Aug 28, 2025Facility evaluation reportReport on file

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

Aug 7, 2025Complaint investigation reportReport on file

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

Aug 7, 2025Complaint investigation reportReport on file

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

Aug 7, 2025Facility evaluation reportReport on file

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

Jul 29, 2025Complaint investigation reportReport on file

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

Jul 15, 2025Facility evaluation reportReport on file

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

Apr 3, 2025Facility evaluation reportReport on file

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

Mar 21, 2025Complaint investigation reportReport on file

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

Mar 21, 2025Complaint investigation reportReport on file

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

Mar 21, 2025Complaint investigation reportReport on file

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

Mar 21, 2025Facility evaluation reportReport on file

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

Feb 4, 2025Facility evaluation reportReport on file

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

Jan 30, 2025Complaint investigation reportReport on file

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

Jan 30, 2025Complaint investigation reportReport on file

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

Jan 30, 2025Complaint investigation reportReport on file

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

Jan 9, 2025Complaint investigation reportSubstantiated

Allegation investigated: -Staff are mishandling the residents medications. -Staff are not being properly trained.

Licensing Program Analysts (LPAs) Marisol Cuadra and Robert Frank conducted an unannounced visit and met with Business Offica Manager, Serina Barreda and Denise Downey, Executive Director. Complainant alleges multiple allegations that are noted above and referenced below in detail. Staff are mishandling the residents’ medications - Complainant and Co-complainant (added 10/11/2024) allege that facilty fails to administer medication as prescribed by doctor, not limited to missed doses of insulin, glucose readings, late doses and charting medication has been administered but has not. Complainant also informs of medication not being destroyed per regulation. Based on record review CCL has received multiple self-report incidents of medication error. On 6/17/2024 the Med Tech failed to assist with R1s blood glucose check subsequently resulted in R1s missed insulin. This was a self-reported incident submitted to CCL on 6/27/2024. On 5/24/2024 CCL received a self-reported incident that on 5/23the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 21-AS-20240703123817
Jan 9, 2025Complaint investigation reportSubstantiated

Allegation investigated: -Facility failed to notify residents of the sale of the property.

Licensing Program Analysts (LPAs) Marisol Cuadra and Robert Frank conducted an unannounced visit and met with Business Offica Manager, Serina Barreda and Denise Downey, Executive Director. The Department received an allegation of facility failed to notify residents of the sale of the property. On 11/19/24 the reporting party have raised concerns about the facility have been sold without notifying the residents. Per reporting party, they heard the news from three people including one staff. On 11/25/24, LPA conducted 10-day and conducted interviews with acting Administrator who provided LPA with a letter from new management dated 11/20/24 addressed to residents and their responsible parties notifying them that there was a new management company for the facility, the transition is set to take effect January 1st, 2025 (or upon approval by the state of California). Based on records review of facility admission agreement revised 05-20-2022, appendix B pg#35 states the following: “TERMINATIOthe state’s words, verbatim · CDSS document, Jan 9, 2025 · control 21-AS-20241119162140
Jan 7, 2025Facility evaluation reportReport on file

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

202420 state visits · 28 documents
Dec 31, 2024Complaint investigation reportUnsubstantiated

Allegation investigated: Licensee does not ensure that the facility has an adequate supply of food for residents in care

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken and documents obtained and reviewed. In addition, unannounced inspections were made of the facility's food supply on three or more occasions. The following determinations are made: Complainant alleges that the facility does not have enough food for the residents in care; Unannounced site visits made to the facility on 11/13/24, 11/21/24, 12/5/24, 12/19/24 confirmed that sufficient fresh and non perishable food was observed on site that meets or exceeds the requirements of Title Twenty - Two; On 12/5 and 12/19/24, plated lunches were observed to meet regulations. Three Food Service staff deny that food service has been inadequate. Although the allegation that Licensee does not ensure that the facility has an adequate supply of food for residents in care may be true, based upon the observations and statements, therethe state’s words, verbatim · CDSS document, Dec 31, 2024 · control 21-AS-20241113121445
Dec 31, 2024Complaint investigation reportUnsubstantiated

Allegation investigated: Facility staff did not dispense medication accurately resulting in resident's death

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. An anonymous Complainant has alleged that Resident R1 was administered morphine prescribed for another resident and that R1 died as a result. Based upon statements and documents reviewed the following determinations are made: R1 was prescribed morphine while on Hospice for pain following a fall on 11/2; R1 died on 11/9/2024; Facility Health and Wellness Director denies that R1 was given morphine prescribed for another resident and states R1 was administered morphine as directed that was prescribed for R1; The Death certificate for R1 gives the cause of death as Alzheimer's Disease with several other contributing factors, none of which result from medication or toxicity; no autopsy was done on R1. Although the allegation may be valid, based upon documents and statements, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the allegation ithe state’s words, verbatim · CDSS document, Dec 31, 2024 · control 21-AS-20241112160143
Dec 31, 2024Complaint investigation reportReport on file

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

Dec 26, 2024Facility evaluation reportReport on file

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

Dec 9, 2024Complaint investigation reportUnsubstantiated

Allegation investigated: -Staff are transporting clients in an unsafe manner. -Staff are mismanaging resident medication. -Staff do not have adequate training. -Facility telephone is not maintained in working order. -Facility is in disrepair. -Staff do not maintain a comfortable temperature for residents at all times. -Staff do not ensure that residents are fed nutritous meals in the quantity or of the quality required to meet resident needs. -Staff do not have sufficient supplies to meet the needs of residents in care. -Staff are not keeping the facility clean and sanitary. -Staff are not following reporting requirements.

Licensing Program Analyst (LPA) Cuadra and support staff Ethel Contreras arrived unannounced for the purpose of delivering findings on this complaint and met with Serina Barreda, Business Office Manager. Complainant alleges multiple allegations that are noted above and referenced below in detail. The complainant is anonymous, and no contact information was provided to obtain additional details on the alleged allegations. Staff are transporting clients in an unsafe manner- Complainant alleges that the facility van is operated by staff without the proper issued driver license, facility is in despair and routine maintenance is not preformed. During the course of the investigation LPA obtained records to ensure vehicle maintenance and operation meets regulation. LPA obtained records of vehicle maintenance, transporting logbook, current registration and insurance and staff that operates vehicle CA driver’s license. Although the allegation may have happened or is valid, there is not a preponthe state’s words, verbatim · CDSS document, Dec 9, 2024 · control 21-AS-20240722094535
Dec 9, 2024Complaint investigation reportUnsubstantiated

Allegation investigated: -Facility is overcharging resident in care. -Staff does not communicate with responsible party in a timely manner.

Licensing Program Analyst (LPA) Cuadra and support staff Ethel Contreras arrived unannounced for the purpose of delivering findings on this complaint and met with Serina Barreda, Business Office Manager. Complainant alleges multiple allegations that are noted above and referenced below in detail. Facility is overcharging resident in care, Staff does not communicate with responsible party in a timely manner - Complaint alleges that resident’s responsible party made multiple attempts to contact the facility by telephone to notify them that the resident would not be returning to the facility following a hospital stay. Complainant was not able to provide proof that notification was sent in writing, After not receiving a response, the responsible party came to the facility and removed all of resident’s personal items. Two of two staff interviewed denied receiving a phone call or email prior to the move-out date. Review of Admission Agreement indicated that termination of the agreement requithe state’s words, verbatim · CDSS document, Dec 9, 2024 · control 21-AS-20240711134704
Dec 5, 2024Facility evaluation reportReport on file

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

Nov 21, 2024Complaint investigation reportUnsubstantiated

Allegation investigated: Facility does not have adequate staff to meet residents needs.

Licensing Program Analyst (LPA) Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with ***** and discussed the disposition of the allegation that Facility does not have adequate staff to meet the residents' needs. Complainant is Anonymous without contact information and has alleged inadequate hydration for residents, lack of sufficient staff and products (assumed to be harmful) assessable to memory care residents. During the course of this investigation documents were reviewed and four unannounced site visits were made to facility. At each unannounced site visit, staffing was sufficient to meet the needs of the residents, hydration stations were observed available to the residents and no harmful products were observed to be accessible to the residents. Although the allegation may be true, or valid, based upon the documents, obsservations and statements, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore,the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 21-AS-20241003142003
Nov 21, 2024Complaint investigation reportReport on file

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

Nov 13, 2024Facility evaluation reportReport on file

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

Nov 12, 2024Facility evaluation reportReport on file

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

Oct 25, 2024Facility evaluation reportReport on file

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

Oct 8, 2024Facility evaluation reportReport on file

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

Sep 10, 2024Facility evaluation reportReport on file

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

Aug 21, 2024Complaint investigation reportUnsubstantiated

Allegation investigated: Staff did not provide resident with water for an extended period of time

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced at facility to deliver complaint findings. LPA met with Interim Administrator Nancy Steers-Crist. Staff did not provide resident with water for an extended period of time – Complainant alleges on June 27th, resident (R1) was sitting outside in the courtyard for 4-6hrs and facility staff did not offer any water to R1 during the time the resident was seated outside. During complaint investigation LPA conducted 4 unannounced visits to the facility (7/7-7/16-7/30-8/15/2024). On each of the visit’s LPA observed a large water dispenser and a pitcher of juice at both kitchenettes (east & west) and additional pitchers of water and juice in both kitchenette refrigerators (see pictures). LPA was informed facility’s hydration protocol for residents is: There are two water stations on each side (east & west) of the facility and caregivers give out and check on hydration of residents every hour to 2 hours (so if they decline water othe state’s words, verbatim · CDSS document, Aug 21, 2024 · control 21-AS-20240703140453
Aug 21, 2024Complaint investigation reportReport on file

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

Aug 13, 2024Facility evaluation reportReport on file

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

Jun 4, 2024Complaint investigation reportSubstantiated

Allegation investigated: Facility does not have adequate staffing Staff do not timely answer the facility telephone

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint findings regarding the allegations listed above and met with Irene Hernandez, Regional Vice President as Administrator was not available. Facility does not have adequate staffing – Complainant alleges lack of staff throughout the facility including unmanned front desk throughout the day. Facility documents obtained on 5/23/2024 and interview with S1 & S2 revealed this 2-sided full dementia facility currently has 43 residents, of which 8 are 2 person assists and 35 are one person assist. Facility has 2 med techs on AM & PM shifts, one on each side. There is approximately 4 caregivers on AM & PM shifts (2 on each side) with hopes of a floater each day on each shift, and 2 caregivers for the nigh time (1 on each side). LPAs interviews revealed concluding information that facility is short staffed and makes attempts to hire. LPAs interview with S1 revealed There has not been a full time receptionist sinthe state’s words, verbatim · CDSS document, Jun 4, 2024 · control 21-AS-20240521215956
May 23, 2024Complaint investigation reportSubstantiated

Allegation investigated: Staff are not current on required trainings

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and delivered findings regarding the allegation listed above and met with Business office Manager (BOM), Serina Barreda and Nurse Consultant Jennifer Rice as Administrator was not available. During investigation LPA made observations, reviewed documents and conducted interviews. Staff are not current on required trainings- Complaint alleges care staff’s required CPR & First Aid trainings are not current, along with dementia training, and medication training. Sample review of three (3) Medication Technician’s(Med Techs)(S1-S3) and six (6) caregivers(S4-S9) files reviewed by LPA, BOM, and Nurse Consultant on 5/23/2024 revealed all dementia training was either insufficient or was not completed, medication training was insufficient or not completed, & only one AM caregiver (S4) had current first aid. Therefore, the allegation, Staff are not current on required trainings is found to be Sthe state’s words, verbatim · CDSS document, May 23, 2024 · control 21-AS-20240521080908
May 23, 2024Complaint investigation reportReport on file

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

May 20, 2024Complaint investigation reportSubstantiated

Allegation investigated: Staff are not managing resident's medication properly

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and delivered findings regarding the allegation listed above and met with Business office Manager, Serina Barreda and Nurse Consultant Jennifer Rice as Administrator was not available. During investigation LPA made observations, reviewed documents and conducted interviews. Staff are not managing resident’s medication properly- Complainant alleges residents are missing medications and the medication room is not in compliance. Documents obtained from facility indicate on 5/9/2024 resident R1 did not received their 4:30pm insulin dosage. Doctors orders dated 4/15/2024 indicate R1 is to have blood sugar checks and prior to each meal three scheduled insulin doses per day. Record review and Interview with Administrator on 5/17/2024 confirmed staff (S1) left facility without providing/administering resident’s scheduled insulin and or designating other staff to administer. Continue on LIC90the state’s words, verbatim · CDSS document, May 20, 2024 · control 21-AS-20240516095437
May 9, 2024Complaint investigation reportSubstantiated

Allegation investigated: Staff are not ensuring residents have had their annual medical assessments

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and delivered findings regarding the allegation listed above and met with Administrator Antonette Edwards and Director of Sales and Marketing, Jeff Putnam & Nurse Consultant Jennifer Rice. During investigation LPA reviewed documents and conducted interviews. Staff are not ensuring residents have had their annual medical assessments- Complainant alleges residents are not getting updated annual physician’s reports as required. Per regulation 87705 ( c)(5) residents with a dementia diagnosis shall have an annual medical assessment. Documents obtained from facility indicate residents R1-R11 all have a dementia diagnosis on medical assessment’s and are between two and six years over due for annual medical assessments. Continue on LIC9099-C Substantiatedthe state’s words, verbatim · CDSS document, May 9, 2024 · control 21-AS-20240502092820
Apr 17, 2024Facility evaluation reportReport on file

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

Mar 27, 2024Complaint investigation reportSubstantiated

Allegation investigated: Facility is in financial distress

Licensing Program Analyst's (LPAs) Hansen & Florio arrived unannounced on this day for the purpose of delivering findings of the above allegation. During the course of this investigation LPA conducted interviews, made observations and engaged the Departments Solvency Auditor to assist in determining if the facilty is experiencing finical distress. LPA met with Marketing Director/Assist. ED Christina Cruz. The Departments Audit Section sent out an engagement letter and LIC 401 & LIC 403 form to Joseph Hansen, administrator on 12/28/2023. The facility did not provide the requested documentation failing to meet deadline on 1/29/2024. The Audit Section made second request on 2/20/2024 requesting compliance to determine solvency. Administrator deferred to corporate members and two additional requests were made on 2/9/2024 and 2/21/2024, facilty failed to meet deadline and provide requested information. LPA conducted interviews and information was provided in support that the facilty is expethe state’s words, verbatim · CDSS document, Mar 27, 2024 · control 21-AS-20230803084501
Mar 27, 2024Complaint investigation reportReport on file

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

Feb 20, 2024Facility evaluation reportReport on file

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

Jan 23, 2024Complaint investigation reportSubstantiated

Allegation investigated: Facilty did not ensure residents room was clean, safe and sanitary

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. During the course of this investigation LPA conducted interviews, made observations, and obtained documents regarding the allegation. LPA met with Joseph Hansen, Executive Director. Facility did not ensure residents room was clean, safe and sanitary – Complainant alleges rooms are not cleaned by staff leaving vomit, feces and or urine on the floor, bedding, furniture, and floor, urine soaked clothing on the floor that had feces in them as well as stool in bathroom trashcan on one occasion. Interviews with staff revealed during that time period housekeeping staff was minimal, lacking the ability to properly clean facility. Outside party confirmed cleaning was not available for a day or two after request, which was sometimes completed by maintenance. Continue on LIC9099-C Substantiatedthe state’s words, verbatim · CDSS document, Jan 23, 2024 · control 21-AS-20230824155633
Jan 23, 2024Complaint investigation reportReport on file

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

20234 state visits · 6 documents
Oct 2, 2023Complaint investigation reportSubstantiated

Allegation investigated: Personal Rights

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and delivered findings regarding the allegation listed above and met with Executive Director Joseph Hansen, Health Services Director Kimiyo Jones, & Business Office Director Christina Cruz. During investigation LPA reviewed documents, made observations, and conducted interviews. Personal Rights - Complainant alleges resident's (R1) room was not locked as requested and another resident entered room and assaulted R1. Community Care Licensing (CCL) received emails on 9/29/2023 indicating on the late evening of 9/27/2023/early morning of 9/28/2023 a resident (R2) had entered R1's room through the apartment door and picked up a shoe and hit R1 in the leg. Documents obtained from facility show R1's service plan indicate no cognitive impairment noted of 8/3/2023 based on current physician’s report. Continue on LIC9099-C Substantiatedthe state’s words, verbatim · CDSS document, Oct 2, 2023 · control 21-AS-20230929111257
Oct 2, 2023Complaint investigation reportUnsubstantiated

Allegation investigated: Resident sustained unexplained injuries while in care- Staff did not seek timely medical attention for resident- Staff did not administer resident’s insulin in a timely manner- Facility staff did not meet residents care needs-

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. During the course of this investigation LPA conducted interviews, made observations, and obtained documents regarding the allegation. LPA met with Joseph Hansen, Executive Director, Christina Cruz, Business Office Director, & Kimiyo Jones, Health Services Director. Resident sustained unexplained injuries while in care – Complainant alleges resident fell multiple times. Documents obtained during investigation from facility indicate resident had documented falls multiple times, some sustaining injuries and some not, and with 2 times resulting in resident going to the hospital. Resident records show not requiring needing one to one care. Facility submitted required incident reports to the department. Based on review of reports and interviews the department is not able to provethe state’s words, verbatim · CDSS document, Oct 2, 2023 · control 21-AS-20230706090520
Sep 21, 2023Complaint investigation reportSubstantiated

Allegation investigated: Insufficient staffing to meet the needs of all residents Facility not able to supply appropriate incontinent care products Staff are mismanaging residents medication Staff are not following resident's care needs Staff are not providing activities for residents Facilities transportation not operational

LIcensing Program Analyst (LPA) Hansen arrived unannounced on this day for the purpose of delivering findings of the above allegations. During the course of this investigation LPA conducted interviews, made observations, and obtained documents regarding the allegations. LPA met with Christina Cruz, Assistant Executive Director & Kimiyo Jones Health Services Director. Insufficient staffing to meet the needs of all residents – Facility not able to supply appropriate incontinent care products- Complaint alleges on the PM shift (2pm – 11:30pm) there is one staff for 33 residents on the east side and one staff for 11 residents on the west side of the dementia facility, with an additional staff that is to help both sides but does not. LPA conducted interviews with 6 staff, staff (S3) informed in July/August,2023 many days from 2-10:30pm there was only 1 caregiver on each side (east & west) to take care of the residents needs, sometimes there was a floater staff if the facility could get to cthe state’s words, verbatim · CDSS document, Sep 21, 2023 · control 21-AS-20230803084501
Sep 12, 2023Facility evaluation reportReport on file

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

Aug 31, 2023Complaint investigation reportSubstantiated

Allegation investigated: Facility did not provide resident with a safe, healthful, and comfortable accommodations

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. During the course of this investigation LPA conducted interviews, made observations, and obtained documents regarding the allegation. LPA met with Christina Cruz, Interim Executive Director. Facility did not provide resident with a safe, healthful, and comfortable accommodations -Complainant alleges facility had previous knowledge about certain residents violent tendencies and did not address and protect other residents. Community Care Licensing (CCL) received an incident report on 6/10/2023 of Resident (R2) assaulting another resident on 6/9/2023. On 6/22/2023 CCL received another incident report occurring on 6/21/2023 where resident R2 entered R1’s bedroom resulting in a physical altercation, causing bruising to R1’s right arm (photos provided). Continue on LIC9099-C Substhe state’s words, verbatim · CDSS document, Aug 31, 2023 · control 21-AS-20230623131207
Aug 31, 2023Complaint investigation reportReport on file

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

Beside homes the same size
Type A citations19typical 1
Type B citations16typical 1
Substantiated complaints36typical 2
Total complaints34typical 7
State visits on file87typical 19
“Typical” is the statewide median across the 1,244 licensed larger communities (16+ beds) in the state record — larger, longer-licensed homes accumulate more visits and reports, so compare like with like. One complaint can contain several allegations. Counts cover this license since 2017.
Year-by-year trend
YearVisitsDocumentsSubstantiated20251221220242028620239124202291012021252
An “unsubstantiated” complaint is not a finding of wrongdoing — it means the state investigated and could not confirm the allegation. Outcome words are the state’s own; we never grade, score, or color a record.Operate this home? Respond to or correct any document here, free. Respond or correct →

See an error in these counts? Report it — free →

$6,000$9,000 /mo
our estimate — Sonoma County band, market research June 2026; not this home’s quoted price
$3,500 · statewide low$9,000 · statewide high
California’s public record holds no per-home price, so we never invent one.
Ways families pay here
Private pay — ask what the base rate includes and what’s billed separately.SSI/SSP — California’s board-and-care payment standard is $1,626.07/mo (2026): $1,444.07 to the home, $182 stays with the resident.Medi-Cal ALW — this home isn’t on the DHCS waiver list (checked August 9, 2026). Details →

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Is Vineyard At Fountaingrove, The licensed?

No — not currently. The CDSS state record checked August 2, 2026 lists Vineyard At Fountaingrove, The in Santa Rosa (Sonoma County), California license #496803698, as “Closed, Change Of Ownership, formerly licensed for 64 residents. State records list 74 inspection and complaint documents since 2021; the most recent, a facility evaluation report dated October 2, 2025, appears in the inspection record on this page.

Can Vineyard At Fountaingrove, The care for dementia, hospice, bedridden, or non-ambulatory residents?

From the CDSS license record, checked August 2, 2026.

The CDSS license record checked August 2, 2026 lists Vineyard At Fountaingrove, The with clearances for dementia / memory care, hospice care, and bedridden; it does not list wheelchair / non-ambulatory. A clearance that is not on file is not a “no” — it may simply be unrecorded, so if your family needs one of these, ask the home directly and confirm its current scope on a tour.

Wheelchair / non-ambulatoryDementia / memory careHospice careBedridden

From the California state record. Some approvals are bed- or room-specific — always confirm current scope with the facility.

What the state record says, word for word
Verbatim, from the CDSS license record64 NONABMULATORY, OF WHICH 12 MAY BE BEDRIDDEN. HOSPICE WAIVER GRANTED FOR 10. NEW MGMT CO. ONELIFE SENIOR LIVING LLC, FM SANTA ROSA INVESTORS, EFFECTIVE 2/20/25.

How much does Vineyard At Fountaingrove, The cost?

California's public licensing record does not include Vineyard At Fountaingrove, The's monthly price, so we never show or estimate one for a specific home. As county-level context only, assisted living in Sonoma County typically runs $6,000–$9,000/mo and small board-and-care homes $5,000–$8,000/mo (market research compiled June 2026 — ranges, not quotes; California's 2026 SSI/SSP board-and-care payment standard is $1,626.07/month, of which $1,444.07 is the room-and-board portion paid to the home). Ask the home for its own rate sheet and what the base rate includes — or use the cost section at the top of this page.

Does Vineyard At Fountaingrove, The accept Medi-Cal or the Assisted Living Waiver?

Vineyard At Fountaingrove, The is not in the DHCS Assisted Living Waiver participant record we checked August 9, 2026 — that list covers only the state's ALW program, not a home's own payment policies, so ask the home directly about private Medi-Cal arrangements. The waiver pays for assisted-living care services (not room and board) at participating homes; every DHCS-listed home appears on our statewide Medi-Cal page.

Assisted living on Medi-Cal in California →See the DHCS list →

How full it was at the last state visit

26 of 64 beds occupied (41%) when the state visited on January 9, 2025. Availability changes constantly — confirm a current opening with the home.

What do state inspections show for Vineyard At Fountaingrove, The?

Verbatim from CDSS complaint-investigation reports — the state's own words, never summarized by us. Record checked August 2, 2026.

The CDSS state record checked August 2, 2026 lists 87 state visits and 74 dated documents since 2021 for Vineyard At Fountaingrove, The; 25 complaint-investigation narratives are transcribed verbatim below. The most recent, dated January 9, 2025, records an allegation the state marked “Substantiated. Open any entry to read the state's full finding, word for word.

Most licensed homes receive some findings over 36 months; what matters is what was found and whether it was corrected. Counts here are shown compared with homes of similar size, and the state's own words appear in full below.

25 transcribed reports on file

2025

Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewed-Staff are mishandling the residents medications. -Staff are not being properly trained.
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analysts (LPAs) Marisol Cuadra and Robert Frank conducted an unannounced visit and met with Business Offica Manager, Serina Barreda and Denise Downey, Executive Director. Complainant alleges multiple allegations that are noted above and referenced below in detail. Staff are mishandling the residents’ medications - Complainant and Co-complainant (added 10/11/2024) allege that facilty fails to administer medication as prescribed by doctor, not limited to missed doses of insulin, glucose readings, late doses and charting medication has been administered but has not. Complainant also informs of medication not being destroyed per regulation. Based on record review CCL has received multiple self-report incidents of medication error. On 6/17/2024 the Med Tech failed to assist with R1s blood glucose check subsequently resulted in R1s missed insulin. This was a self-reported incident submitted to CCL on 6/27/2024. On 5/24/2024 CCL received a self-reported incident that on 5/23CDSS inspection report, January 9, 2025 · control 21-AS-20240703123817
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewed-Facility failed to notify residents of the sale of the property.
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analysts (LPAs) Marisol Cuadra and Robert Frank conducted an unannounced visit and met with Business Offica Manager, Serina Barreda and Denise Downey, Executive Director. The Department received an allegation of facility failed to notify residents of the sale of the property. On 11/19/24 the reporting party have raised concerns about the facility have been sold without notifying the residents. Per reporting party, they heard the news from three people including one staff. On 11/25/24, LPA conducted 10-day and conducted interviews with acting Administrator who provided LPA with a letter from new management dated 11/20/24 addressed to residents and their responsible parties notifying them that there was a new management company for the facility, the transition is set to take effect January 1st, 2025 (or upon approval by the state of California). Based on records review of facility admission agreement revised 05-20-2022, appendix B pg#35 states the following: “TERMINATIOCDSS inspection report, January 9, 2025 · control 21-AS-20241119162140

2024

Complaint investigationAllegation reviewed · Unsubstantiated
Allegation the state reviewedLicensee does not ensure that the facility has an adequate supply of food for residents in care
State's findingUnsubstantiatedThe state investigated but could not confirm the allegation. This is not a finding of wrongdoing.
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken and documents obtained and reviewed. In addition, unannounced inspections were made of the facility's food supply on three or more occasions. The following determinations are made: Complainant alleges that the facility does not have enough food for the residents in care; Unannounced site visits made to the facility on 11/13/24, 11/21/24, 12/5/24, 12/19/24 confirmed that sufficient fresh and non perishable food was observed on site that meets or exceeds the requirements of Title Twenty - Two; On 12/5 and 12/19/24, plated lunches were observed to meet regulations. Three Food Service staff deny that food service has been inadequate. Although the allegation that Licensee does not ensure that the facility has an adequate supply of food for residents in care may be true, based upon the observations and statements, thereCDSS inspection report, December 31, 2024 · control 21-AS-20241113121445
Complaint investigationAllegation reviewed · Unsubstantiated
Allegation the state reviewedFacility staff did not dispense medication accurately resulting in resident's death
State's findingUnsubstantiatedThe state investigated but could not confirm the allegation. This is not a finding of wrongdoing.
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. An anonymous Complainant has alleged that Resident R1 was administered morphine prescribed for another resident and that R1 died as a result. Based upon statements and documents reviewed the following determinations are made: R1 was prescribed morphine while on Hospice for pain following a fall on 11/2; R1 died on 11/9/2024; Facility Health and Wellness Director denies that R1 was given morphine prescribed for another resident and states R1 was administered morphine as directed that was prescribed for R1; The Death certificate for R1 gives the cause of death as Alzheimer's Disease with several other contributing factors, none of which result from medication or toxicity; no autopsy was done on R1. Although the allegation may be valid, based upon documents and statements, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the allegation iCDSS inspection report, December 31, 2024 · control 21-AS-20241112160143
Complaint investigationAllegation reviewed · Unsubstantiated
Allegation the state reviewed-Staff are transporting clients in an unsafe manner. -Staff are mismanaging resident medication. -Staff do not have adequate training. -Facility telephone is not maintained in working order. -Facility is in disrepair. -Staff do not maintain a comfortable temperature for residents at all times. -Staff do not ensure that residents are fed nutritous meals in the quantity or of the quality required to meet resident needs. -Staff do not have sufficient supplies to meet the needs of residents in care. -Staff are not keeping the facility clean and sanitary. -Staff are not following reporting requirements.
State's findingUnsubstantiatedThe state investigated but could not confirm the allegation. This is not a finding of wrongdoing.
Licensing Program Analyst (LPA) Cuadra and support staff Ethel Contreras arrived unannounced for the purpose of delivering findings on this complaint and met with Serina Barreda, Business Office Manager. Complainant alleges multiple allegations that are noted above and referenced below in detail. The complainant is anonymous, and no contact information was provided to obtain additional details on the alleged allegations. Staff are transporting clients in an unsafe manner- Complainant alleges that the facility van is operated by staff without the proper issued driver license, facility is in despair and routine maintenance is not preformed. During the course of the investigation LPA obtained records to ensure vehicle maintenance and operation meets regulation. LPA obtained records of vehicle maintenance, transporting logbook, current registration and insurance and staff that operates vehicle CA driver’s license. Although the allegation may have happened or is valid, there is not a preponCDSS inspection report, December 9, 2024 · control 21-AS-20240722094535
Complaint investigationAllegation reviewed · Unsubstantiated
Allegation the state reviewed-Facility is overcharging resident in care. -Staff does not communicate with responsible party in a timely manner.
State's findingUnsubstantiatedThe state investigated but could not confirm the allegation. This is not a finding of wrongdoing.
Licensing Program Analyst (LPA) Cuadra and support staff Ethel Contreras arrived unannounced for the purpose of delivering findings on this complaint and met with Serina Barreda, Business Office Manager. Complainant alleges multiple allegations that are noted above and referenced below in detail. Facility is overcharging resident in care, Staff does not communicate with responsible party in a timely manner - Complaint alleges that resident’s responsible party made multiple attempts to contact the facility by telephone to notify them that the resident would not be returning to the facility following a hospital stay. Complainant was not able to provide proof that notification was sent in writing, After not receiving a response, the responsible party came to the facility and removed all of resident’s personal items. Two of two staff interviewed denied receiving a phone call or email prior to the move-out date. Review of Admission Agreement indicated that termination of the agreement requiCDSS inspection report, December 9, 2024 · control 21-AS-20240711134704
Complaint investigationAllegation reviewed · Unsubstantiated
Allegation the state reviewedFacility does not have adequate staff to meet residents needs.
State's findingUnsubstantiatedThe state investigated but could not confirm the allegation. This is not a finding of wrongdoing.
Licensing Program Analyst (LPA) Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with ***** and discussed the disposition of the allegation that Facility does not have adequate staff to meet the residents' needs. Complainant is Anonymous without contact information and has alleged inadequate hydration for residents, lack of sufficient staff and products (assumed to be harmful) assessable to memory care residents. During the course of this investigation documents were reviewed and four unannounced site visits were made to facility. At each unannounced site visit, staffing was sufficient to meet the needs of the residents, hydration stations were observed available to the residents and no harmful products were observed to be accessible to the residents. Although the allegation may be true, or valid, based upon the documents, obsservations and statements, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore,CDSS inspection report, November 21, 2024 · control 21-AS-20241003142003
Complaint investigationAllegation reviewed · Unsubstantiated
Allegation the state reviewedStaff did not provide resident with water for an extended period of time
State's findingUnsubstantiatedThe state investigated but could not confirm the allegation. This is not a finding of wrongdoing.
Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced at facility to deliver complaint findings. LPA met with Interim Administrator Nancy Steers-Crist. Staff did not provide resident with water for an extended period of time – Complainant alleges on June 27th, resident (R1) was sitting outside in the courtyard for 4-6hrs and facility staff did not offer any water to R1 during the time the resident was seated outside. During complaint investigation LPA conducted 4 unannounced visits to the facility (7/7-7/16-7/30-8/15/2024). On each of the visit’s LPA observed a large water dispenser and a pitcher of juice at both kitchenettes (east & west) and additional pitchers of water and juice in both kitchenette refrigerators (see pictures). LPA was informed facility’s hydration protocol for residents is: There are two water stations on each side (east & west) of the facility and caregivers give out and check on hydration of residents every hour to 2 hours (so if they decline water oCDSS inspection report, August 21, 2024 · control 21-AS-20240703140453
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedFacility does not have adequate staffing Staff do not timely answer the facility telephone
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint findings regarding the allegations listed above and met with Irene Hernandez, Regional Vice President as Administrator was not available. Facility does not have adequate staffing – Complainant alleges lack of staff throughout the facility including unmanned front desk throughout the day. Facility documents obtained on 5/23/2024 and interview with S1 & S2 revealed this 2-sided full dementia facility currently has 43 residents, of which 8 are 2 person assists and 35 are one person assist. Facility has 2 med techs on AM & PM shifts, one on each side. There is approximately 4 caregivers on AM & PM shifts (2 on each side) with hopes of a floater each day on each shift, and 2 caregivers for the nigh time (1 on each side). LPAs interviews revealed concluding information that facility is short staffed and makes attempts to hire. LPAs interview with S1 revealed There has not been a full time receptionist sinCDSS inspection report, June 4, 2024 · control 21-AS-20240521215956
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedStaff are not current on required trainings
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and delivered findings regarding the allegation listed above and met with Business office Manager (BOM), Serina Barreda and Nurse Consultant Jennifer Rice as Administrator was not available. During investigation LPA made observations, reviewed documents and conducted interviews. Staff are not current on required trainings- Complaint alleges care staff’s required CPR & First Aid trainings are not current, along with dementia training, and medication training. Sample review of three (3) Medication Technician’s(Med Techs)(S1-S3) and six (6) caregivers(S4-S9) files reviewed by LPA, BOM, and Nurse Consultant on 5/23/2024 revealed all dementia training was either insufficient or was not completed, medication training was insufficient or not completed, & only one AM caregiver (S4) had current first aid. Therefore, the allegation, Staff are not current on required trainings is found to be SCDSS inspection report, May 23, 2024 · control 21-AS-20240521080908
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedStaff are not managing resident's medication properly
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and delivered findings regarding the allegation listed above and met with Business office Manager, Serina Barreda and Nurse Consultant Jennifer Rice as Administrator was not available. During investigation LPA made observations, reviewed documents and conducted interviews. Staff are not managing resident’s medication properly- Complainant alleges residents are missing medications and the medication room is not in compliance. Documents obtained from facility indicate on 5/9/2024 resident R1 did not received their 4:30pm insulin dosage. Doctors orders dated 4/15/2024 indicate R1 is to have blood sugar checks and prior to each meal three scheduled insulin doses per day. Record review and Interview with Administrator on 5/17/2024 confirmed staff (S1) left facility without providing/administering resident’s scheduled insulin and or designating other staff to administer. Continue on LIC90CDSS inspection report, May 20, 2024 · control 21-AS-20240516095437
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedStaff are not ensuring residents have had their annual medical assessments
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and delivered findings regarding the allegation listed above and met with Administrator Antonette Edwards and Director of Sales and Marketing, Jeff Putnam & Nurse Consultant Jennifer Rice. During investigation LPA reviewed documents and conducted interviews. Staff are not ensuring residents have had their annual medical assessments- Complainant alleges residents are not getting updated annual physician’s reports as required. Per regulation 87705 ( c)(5) residents with a dementia diagnosis shall have an annual medical assessment. Documents obtained from facility indicate residents R1-R11 all have a dementia diagnosis on medical assessment’s and are between two and six years over due for annual medical assessments. Continue on LIC9099-C SubstantiatedCDSS inspection report, May 9, 2024 · control 21-AS-20240502092820
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedFacility is in financial distress
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst's (LPAs) Hansen & Florio arrived unannounced on this day for the purpose of delivering findings of the above allegation. During the course of this investigation LPA conducted interviews, made observations and engaged the Departments Solvency Auditor to assist in determining if the facilty is experiencing finical distress. LPA met with Marketing Director/Assist. ED Christina Cruz. The Departments Audit Section sent out an engagement letter and LIC 401 & LIC 403 form to Joseph Hansen, administrator on 12/28/2023. The facility did not provide the requested documentation failing to meet deadline on 1/29/2024. The Audit Section made second request on 2/20/2024 requesting compliance to determine solvency. Administrator deferred to corporate members and two additional requests were made on 2/9/2024 and 2/21/2024, facilty failed to meet deadline and provide requested information. LPA conducted interviews and information was provided in support that the facilty is expeCDSS inspection report, March 27, 2024 · control 21-AS-20230803084501
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedFacilty did not ensure residents room was clean, safe and sanitary
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. During the course of this investigation LPA conducted interviews, made observations, and obtained documents regarding the allegation. LPA met with Joseph Hansen, Executive Director. Facility did not ensure residents room was clean, safe and sanitary – Complainant alleges rooms are not cleaned by staff leaving vomit, feces and or urine on the floor, bedding, furniture, and floor, urine soaked clothing on the floor that had feces in them as well as stool in bathroom trashcan on one occasion. Interviews with staff revealed during that time period housekeeping staff was minimal, lacking the ability to properly clean facility. Outside party confirmed cleaning was not available for a day or two after request, which was sometimes completed by maintenance. Continue on LIC9099-C SubstantiatedCDSS inspection report, January 23, 2024 · control 21-AS-20230824155633

2023

Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedPersonal Rights
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and delivered findings regarding the allegation listed above and met with Executive Director Joseph Hansen, Health Services Director Kimiyo Jones, & Business Office Director Christina Cruz. During investigation LPA reviewed documents, made observations, and conducted interviews. Personal Rights - Complainant alleges resident's (R1) room was not locked as requested and another resident entered room and assaulted R1. Community Care Licensing (CCL) received emails on 9/29/2023 indicating on the late evening of 9/27/2023/early morning of 9/28/2023 a resident (R2) had entered R1's room through the apartment door and picked up a shoe and hit R1 in the leg. Documents obtained from facility show R1's service plan indicate no cognitive impairment noted of 8/3/2023 based on current physician’s report. Continue on LIC9099-C SubstantiatedCDSS inspection report, October 2, 2023 · control 21-AS-20230929111257
Complaint investigationAllegation reviewed · Unsubstantiated
Allegation the state reviewedResident sustained unexplained injuries while in care- Staff did not seek timely medical attention for resident- Staff did not administer resident’s insulin in a timely manner- Facility staff did not meet residents care needs-
State's findingUnsubstantiatedThe state investigated but could not confirm the allegation. This is not a finding of wrongdoing.
Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. During the course of this investigation LPA conducted interviews, made observations, and obtained documents regarding the allegation. LPA met with Joseph Hansen, Executive Director, Christina Cruz, Business Office Director, & Kimiyo Jones, Health Services Director. Resident sustained unexplained injuries while in care – Complainant alleges resident fell multiple times. Documents obtained during investigation from facility indicate resident had documented falls multiple times, some sustaining injuries and some not, and with 2 times resulting in resident going to the hospital. Resident records show not requiring needing one to one care. Facility submitted required incident reports to the department. Based on review of reports and interviews the department is not able to proveCDSS inspection report, October 2, 2023 · control 21-AS-20230706090520
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedInsufficient staffing to meet the needs of all residents Facility not able to supply appropriate incontinent care products Staff are mismanaging residents medication Staff are not following resident's care needs Staff are not providing activities for residents Facilities transportation not operational
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
LIcensing Program Analyst (LPA) Hansen arrived unannounced on this day for the purpose of delivering findings of the above allegations. During the course of this investigation LPA conducted interviews, made observations, and obtained documents regarding the allegations. LPA met with Christina Cruz, Assistant Executive Director & Kimiyo Jones Health Services Director. Insufficient staffing to meet the needs of all residents – Facility not able to supply appropriate incontinent care products- Complaint alleges on the PM shift (2pm – 11:30pm) there is one staff for 33 residents on the east side and one staff for 11 residents on the west side of the dementia facility, with an additional staff that is to help both sides but does not. LPA conducted interviews with 6 staff, staff (S3) informed in July/August,2023 many days from 2-10:30pm there was only 1 caregiver on each side (east & west) to take care of the residents needs, sometimes there was a floater staff if the facility could get to cCDSS inspection report, September 21, 2023 · control 21-AS-20230803084501
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedFacility did not provide resident with a safe, healthful, and comfortable accommodations
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. During the course of this investigation LPA conducted interviews, made observations, and obtained documents regarding the allegation. LPA met with Christina Cruz, Interim Executive Director. Facility did not provide resident with a safe, healthful, and comfortable accommodations -Complainant alleges facility had previous knowledge about certain residents violent tendencies and did not address and protect other residents. Community Care Licensing (CCL) received an incident report on 6/10/2023 of Resident (R2) assaulting another resident on 6/9/2023. On 6/22/2023 CCL received another incident report occurring on 6/21/2023 where resident R2 entered R1’s bedroom resulting in a physical altercation, causing bruising to R1’s right arm (photos provided). Continue on LIC9099-C SubsCDSS inspection report, August 31, 2023 · control 21-AS-20230623131207
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedStaff mismanaged resident's medication
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) Cuadra arrived unannounced to initiate a complaint investigation regarding the allegations listed above and met with Executive Director, Eric Perry. There is an allegation of staff mismanaged resident's medication. Per Reporting Party, Resident (R1) was given Coumadin for the first week of their admission back in March 2023, then staff did not give the resident Coumadin (Warfarin) on March 21,22,24 and 27, 2023 due to medication was not included in the facility medication administration records (MAR). In April 2023, R1's anti-coagulation medication was increased to 4 1/2mg (miligrams) on Mondays (M), Wednesday (W), Thursday (Th) and Friday (F). Also, 3mg on Tuesdays (T). Per supporting documentation obtained Kaiser faxed over the instructions/ordering on 4/24/23 and then called the facility to make sure the facility received the new increase order but there was no confirmation received from the facility. On 5/8/23, the clinic spoke to the facility nurseCDSS inspection report, May 19, 2023 · control 21-AS-20230518111323

Transcribed from CDSS complaint-investigation reports · record checked August 2, 2026.

What the state has logged

California has logged 87 state visits for this home as of August 2, 2026. These are the home's own counts, straight from that record — shown beside the statewide median for larger communities (16+ beds), computed across all 1,244 licensed homes of that size, because larger and longer-licensed homes naturally accumulate more visits and reports. They are facts, not a grade — a citation may be minor and since corrected, and an “unsubstantiated” complaint is not a finding of wrongdoing.

Type A citations
19
typical for this size: 1
Type B citations
16
typical for this size: 1
Substantiated complaints
36
typical for this size: 2
Total complaints
34
typical for this size: 7
State visits on file
87
typical for this size: 19
See the full inspection record on the state's site →
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What isn't in the state record

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