Inspection Reports for
Vine Ridge at Cloverdale

The visit was complaint-related due to an incident report of a medication error. Resident 1 was given medication intended for Resident 2, transported to emergency care, but suffered no adverse effects. The facility was found noncompliant and will be cited.

The facility failed to comply with medication administration protocols when Medication Aid MA1 mistakenly gave medications intended for Resident 2 to Resident 1, posing an immediate health and safety risk. The facility has since changed procedures to involve three staff members reviewing After Visit Summaries for residents seen in emergency or primary care settings. The facility will be cited for this deficiency.

The complaint alleged that staff did not provide requested records to a resident’s representative in a timely manner. The allegation was substantiated after investigation.

The investigation found that the facility did not comply with regulations requiring prompt access to resident records, as the requested documents were not provided within the regulated two business days. The allegation was substantiated based on interviews and record review.

The inspection found deficiencies related to staff training documentation, specifically one staff member lacking proof of annual training and another with incomplete training hours. All other staff and resident documentation were found to be in compliance, and medications were properly stored and documented.

The complaint was substantiated based on the preponderance of evidence standard. The allegation was that the physical plant was in disrepair, specifically the floor in the memory care dining/common area being a trip hazard.

The investigation substantiated the complaint, finding that a large portion of the memory care dining/common area floor was bubbled, loose, and raised, creating a safety risk. The facility administrator confirmed the floor had been in disrepair for approximately three months and plans to replace it during the weekend of 9/19/2025 to 9/21/2025.

The facility was generally clean, orderly, and compliant with safety and operational standards, including emergency preparedness and environmental conditions. One deficiency was cited for a staff member not having completed the required Guardian Background Clearance prior to employment. Additionally, flooring in the memory care unit was found to be in disrepair and will be cited under a separate complaint. The annual inspection was not completed and will continue at a later date.

Deficiencies were cited based on a complaint investigation regarding failure to notify the Department of the change of administrator within the required 30-day period. Appeal rights were given.

The licensee failed to notify the Department in writing within thirty days of hiring a new administrator in December 2023, which is a potential risk to the health and safety of residents. Deficiencies were cited under California Code of Regulations, Title 22, Division 6.

The facility was found to be clean, in good repair, and compliant with safety and health regulations in most areas. However, deficiencies were noted in staff training documentation, with 5 out of 5 staff records lacking verification of required training and orientation.

The complaint investigation was substantiated regarding overcharging a resident due to lack of documented reassessment after a significant change in condition. The complaint alleging failure to provide timely copies of records was found to be unfounded.

The investigation substantiated that the facility overcharged a resident for care services by not documenting a reassessment following a significant change in the resident's condition as indicated in the physician's report dated 8/29/2022. Another complaint alleging failure to provide a resident with a copy of records in a timely manner was found to be unfounded.

The complaint investigation addressed allegations of failure to follow Covid protocols, failure to follow resident's care plan, failure to meet reporting requirements, and neglect/lack of supervision resulting in resident elopement. The Covid protocol allegation was substantiated; the care plan and reporting allegations were unsubstantiated; and the neglect/elopement allegation was unfounded.

The complaint that the facility was not following Covid protocols was substantiated with observation of staff not wearing masks. The allegations that staff were not following a resident's care plan and reporting requirements were unsubstantiated. The allegation of neglect/lack of supervision resulting in resident elopement was found to be unfounded with no deficiencies cited.

The facility generally maintained infection control practices including PPE supply, signage, and staff mask use. However, a deficiency was cited related to the elopement of a memory care resident, indicating a failure to meet safety measures for residents with dementia.

The complaint investigation was substantiated for allegations of insufficient staffing and resident needs not being met. The allegation that the administrator lacked qualifications was unsubstantiated.

The investigation substantiated the complaints of insufficient staffing and resident needs not being met, including issues such as staff shortages causing the administrator to cover caregiving duties and residents not consistently receiving assistance with activities of daily living. The allegation regarding administrator qualifications was unsubstantiated.

Complaint was substantiated for failure to follow Covid Mitigation Plan and unsafe, unsanitary conditions. The fingerprint clearance allegation was unsubstantiated.

The investigation substantiated that the facility failed to follow their Covid Mitigation Plan, including failure to notify residents and responsible parties of Covid positive cases and failure to test all staff and residents. The facility was also found not safe and in good repair due to malfunctioning delayed egress doors and evidence of plumbing leaks. The allegation regarding improper fingerprint clearance and association was unsubstantiated.

The complaint investigation was substantiated for failure to ensure resident's personal rights. The allegations regarding retention of a resident with a prohibited condition (staph infection) and failure to meet resident's care needs (weeping wounds and rash) were unsubstantiated.

The complaint that the facility failed to ensure resident's personal rights was substantiated, with evidence that a resident entered other residents' rooms and took their clothes. The allegations that the facility retained a resident with a prohibited condition and failed to meet resident's care needs were unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for insufficient staffing, meaning the allegation was valid based on the preponderance of evidence. Other allegations related to resident feeding, medication handling, facility sanitation, resident fall, incontinence care, laundry services, and adherence to care plans were unsubstantiated.

The complaint of insufficient staffing was substantiated, indicating staff shortages leading to delayed or unmet resident needs. Other allegations including improper feeding, medication mishandling, unsafe and unsanitary conditions, resident fall, unmet incontinence and laundry needs, and failure to follow resident care plans were unsubstantiated due to lack of sufficient evidence.

The complaint investigation was triggered by allegations received on 06/28/2021. The allegations were found unsubstantiated except for one related to medication accessibility to residents, which had been substantiated in a prior complaint received on 06/16/2021.

The investigation found that the facility was clean, the mitigation plan was being followed, and medication administration and record keeping complied with regulations. However, one allegation regarding medication accessibility to residents was substantiated in a prior complaint. Overall, the current allegations were unsubstantiated based on the evidence.

The complaint investigation was substantiated for allegations that staff were not trained and medication was not stored inaccessible to residents. The allegation that the centrally stored medication log was not maintained was unsubstantiated.

The investigation substantiated that staff were not properly trained and medication was not stored inaccessible to residents, posing immediate risks. However, the allegation regarding the centrally stored medication log not being maintained was unsubstantiated.