216804010-7-9-2024-21-AS-VBEI-D74MP2-20240712094623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804010
Report Date: 07/09/2024
Date Signed: 07/09/2024 04:07:13 PM

Substantiated

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
03/01/2024 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20240301160352

FACILITY NAME:	VINCENT, THE		FACILITY NUMBER:	216804010
ADMINISTRATOR:	SHAWN MOONEY		FACILITY TYPE:	740
ADDRESS:	1 LAS GALINAS AVE		TELEPHONE:	(628) 243-3959
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	126	CENSUS: 68	DATE:	07/09/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Health and Wellness Director, Ashley Perrone		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Personal Rights
Staff mismanaged medications

INVESTIGATION FINDINGS:

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At approximately 1:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Health and Wellness Director, Ashley Perrone.

During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Personal Rights and Staff mismanaged medications.” Complainant alleged that facility staff made videos that discussed resident care with other staff members present. Per Complainant, the videos were about 45 minutes long and recorded information that also showed resident medication.
LPA was unable to view the videos as the Complainant did not have a copy of them and was unable to provide additional information regarding the videos.

Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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 5

Control Number 21-AS-20240301160352

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: VINCENT, THE	FACILITY NUMBER: 216804010
	VISIT DATE: 07/09/2024

NARRATIVE

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Continued from LIC9099

LPA conducted an interview with Staff Member 1 (S1). During interview, S1 informed LPA that they were alone in the medication room making a video of themselves when another staff member approached them to provide resident care updates. Per S1, they forgot that the video was still recording. S1 informed LPA that the videos did not contain any identifiable medical information and that the videos had been posted on their personal social media page. S1 immediately deleted the videos when it was discovered that information regarding resident care was included. S1 informed LPA that they had training regarding the incident. Based on interview conducted, this allegation is Substantiated.

Complainant alleged that facility staff mismanaged medications. Per Complainant, Resident 1’s (R1) narcotic medications were found with another resident's narcotic medication when they moved to a new facility. LPA reviewed incident report that was submitted to the Department on 03/04/2024. Report stated that on 02/19/2024, S1 released the resident's narcotic medication to their new facility. On 02/20/2024, it was discovered that R1’s narcotic medication was with this resident's narcotic medication. Per report, R1’s narcotic medication was appropriately destroyed on 02/19/2024 and a new supply of narcotic medication was received on 02/22/2024. Review of R1’s Electronic Medication Administration Record and Physician Orders indicated that their medication was prescribed as a PRN or “as needed” medication. Record review indicated that R1 did not take the PRN medication. Facility submitted documentation to the Department showing that S1 had an in-service training on the following topics: Narcotic, Controlled Substances and Preventing Drug Diversion, Six Rights of Medication Administration, Confidentiality Policy, and Release of Medications. Based on review of documents, this allegation is Substantiated.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An Immediate Civil Penalty in the total amount of $250 is being assessed for a repeat violation of Regulation 87468.2(a)(2) more than once in a 12 month period. (See LIC421FC)**

Licensee submitted Inservice Training for S1 to the Department on 03/04/2024. Deficiency cited for Regulation 87468.2(a)(2) cleared during visit.

Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC809D, LIC421FC (Civil Penalty), Appeal Rights, and Plan of Corrections Letter discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

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
03/01/2024 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20240301160352

FACILITY NAME:	VINCENT, THE		FACILITY NUMBER:	216804010
ADMINISTRATOR:	SHAWN MOONEY		FACILITY TYPE:	740
ADDRESS:	1 LAS GALINAS AVE		TELEPHONE:	(628) 243-3959
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	126	CENSUS:	DATE:	07/09/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Health and Wellness Director, Ashley Perrone		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are not adequately trained

INVESTIGATION FINDINGS:

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At approximately 1:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Health and Wellness Director, Ashley Perrone.

During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation were investigated, “Staff are not adequately trained.”Complainant alleged that facility staff are not adequately trained. Per Complainant, Staff Member 1 (S1) is not adequately trained and has not completed facility training for the past 22 months. Review of S1’s file indicated that they have completed 2023 training as required by Title 22 Regulations. This allegation is Unsubstantiated.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 21-AS-20240301160352

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: VINCENT, THE	FACILITY NUMBER: 216804010
	VISIT DATE: 07/09/2024

NARRATIVE

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Continued from LIC9099A

A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 21-AS-20240301160352

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: VINCENT, THE	FACILITY NUMBER: 216804010
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/19/2024 Section Cited CCR 87468.2(a)(2)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a)...residents...shall have all of the following...:(2) to have their records and personal information remain confidential and to approve their release...This requirement was not met as evidenced by: Based on	1 2 3 4 5 6 7	Licensee submitted Inservice Training for S1 to the Department on the following topics: Narcotic, Controlled Substances and Preventing Drug Diversion, Six Rights of Medication Administration, Confidentiality Policy, and Release of Medications on 03/04/2024. Deficiency cleared during visit.
	8 9 10 11 12 13 14	interviews and document review, Licensee did not comply with the section cited above. Facility staff posted a video with resident care information and failed to ensure narcotic medication confidentiality. This poses an potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5