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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 210108102
Report Date: 02/26/2025
Date Signed: 02/26/2025 10:01:14 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/08/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20250108100016
FACILITY NAME:VILLA MARIN AMBULATORY CARE UNITFACILITY NUMBER:
210108102
ADMINISTRATOR:DURANCZYK, PAULFACILITY TYPE:
741
ADDRESS:100 THORNDALE DRIVETELEPHONE:
(415) 499-8711
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:28CENSUS: 273DATE:
02/26/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Health Services Administrator, Paul Duranczyk, and CEO Nicole MashburnTIME COMPLETED:
10:10 AM
ALLEGATION(S):
1
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9
Staff did not allow resident to continue scheduled provider/resident meeting
Staff did not allow resident to record during resident's meetings
INVESTIGATION FINDINGS:
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On 02/26/2025, Licensing Program Analyst (LPA) Felias arrived at facility unannounced to deliver findings related to the above listed allegations. LPA met with Health Services Administrator, Paul Duranczyk, and CEO, Nicole Mashburn, and explained the purpose of today’s visit.

The California Department of Social Services (the Department) received a complaint related to the rights of Continuing Care Retirement Community (CCRC) residents to meet with staff and record meetings between an individual resident and staff.

During the course of this investigation the Department reviewed records including but not limited to the Villa Marin Residency Agreement for Resident 1 (R1), community resident rosters, community staff rosters and email communications. The Department also conducted interviews with community residents and community staff. A physical inspection of the facility site was also conducted.
Continued on LIC9099C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20250108100016
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VILLA MARIN AMBULATORY CARE UNIT
FACILITY NUMBER: 210108102
VISIT DATE: 02/26/2025
NARRATIVE
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Continued from LIC9099

Allegation 1: Staff did not allow resident to continue scheduled provider/resident meeting.

Based on the documentation reviewed and interviews conducted, staff 1 (S1) met with R1 on December 12, 2024 to discuss information related to R1’s Residential Living Unit (RLU). R1 attempted to record the meeting and S1 declined to give consent for the recording. R1 continued to record and as a result, S1 was unwilling to further participate in the discussion. There is no evidence to suggest that R1 was denied the opportunity to engage in this discussion had it not been recorded therefore the allegation is UNFOUNDED.

A finding of unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Allegation 2: Staff did not allow resident to record during resident's meetings.

Based on the documentation reviewed and interviews conducted, R1 and S1 were meeting on December 12, 2024 to discuss information related to R1’s Residential Living Unit (RLU). The meeting was being held on a voluntary basis by both parties. There is consensus between R1 and S1 that S1 was unwilling to participate in the intended discussion while being recorded. Under California law all parties must consent to the recording of a confidential communication. Based on the investigation conducted, there is no evidence to support that this meeting was held for the purpose of discussing public matters or for the benefit of the residents in the community as a whole. No community residents other than R1 were offered an opportunity to participate in this particular discussion and as such the ensuing communication could have been or would have been considered confidential by S1. If the communication was confidential then R1 would not have the right to record S1 without S1’s consent making the allegation UNFOUNDED.

A finding of unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator and CEO. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2