<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804010
Report Date: 07/24/2024
Date Signed: 07/24/2024 04:58:36 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
03/08/2024 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20240308142252
FACILITY NAME:VINCENT, THEFACILITY NUMBER:
216804010
ADMINISTRATOR:SAM FAYEFACILITY TYPE:
740
ADDRESS:1 LAS GALINAS AVETELEPHONE:
(628) 243-3959
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:126CENSUS: 68DATE:
07/24/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Executive Director, Corrine Bianco, and Health and Wellness Director, Ashley PerroneTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure medications were properly managed for resident in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 12:50PM, Licensing Program Analysts (LPAs) Felias and Loera arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Executive Director/Administrator, Corrine Bianco, and Health and Wellness Director, Ashley Perrone.

During the Investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff did not ensure medications were properly managed for resident in care."
Complainant alleged that the facility ran out of Resident 1 (R1’s) Ativan medication and did not ensure that their refills were replenished timely. Per Complainant, R1 did not receive their Ativan medication during these timeframes: 11/19/2023 through 11/26/2023 and 02/22/2024 through 03/01/2024. Review of R1’s Electronic Medication Authorization Record (EMAR) and Narcotic Log for November 2023 revealed that R1 received their last dose of Ativan on 11/18/2023 and did not receive another dose of Ativan until 11/27/2023.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
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 6
Control Number 21-AS-20240308142252
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: 07/24/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099

Review of R1's file did not indicate any communication to R1's Primary Care Physician or pharmacy regarding refills. Review of R1’s Electronic Medication Authorization Record (EMAR) and Narcotic Log for February and March 2024 revealed that R1 received their last dose of Ativan on 3/2/2024. Review of R1's file indicated that the facility notified R1's Primary Care Physician and pharmacy. Per documentation, the facility was actively attempting to have medication refilled but were unsuccessful. Complaint alleged that during a visit on 3/6/2024, the resident’s behavior was “off.” When staff were questioned about resident’s medication, they indicated that the resident had been out of the medication for a week. Staff interviews conducted indicated that the facility protocol is to contact the Physician and pharmacy at least 7 days prior to a medication running out. Based on document review and interviews conducted, 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 87465(a)(4) more than once in a 12 month period. (See LIC421FC)**


Exit interview conducted. Copy of report, LIC809D, LIC421FC (Civil Penalty), LIC811 (Confidential Names), and Appeal Rights, discussed and provided to Executive Director/Administrator, and Health and Wellness Director. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 21-AS-20240308142252
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: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/25/2024
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care(a) A plan... shall be developed... The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced
1
2
3
4
5
6
7
Licensee to submit self-certification that In-service training will be conducted by POC due date of 07/25/2024. Training to be done for all staff that administer medications reviewing when to order medications per facility protocol. Inservice Training to include the following information: Date of Training,
8
9
10
11
12
13
14
by: Based on document review, interviews, and observations made, Licensee did not comply with the section cited above. R1 did not receive medication as prescribed due to facility running out of their medication. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Training Topics, Job Role, Staff Names and Signatures. Training to be submitted by POC due date of 08/05/2024.
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 BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
03/08/2024 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20240308142252

FACILITY NAME:VINCENT, THEFACILITY NUMBER:
216804010
ADMINISTRATOR:SAM FAYEFACILITY TYPE:
740
ADDRESS:1 LAS GALINAS AVETELEPHONE:
(628) 243-3959
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:126CENSUS: 68DATE:
07/24/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Executive Director, Corrine Bianco, and Health and Wellness Director, Ashley PerroneTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure communication is provided to residents responsible party
Resident sustained unexplained fractured hand
Resident sustained unexplained bruising on shoulder
Facility staff restrained resident
Facility staff did not assist resident with dressing as needed
Facility staff did not meet resident's meal service needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 12:50PM, Licensing Program Analysts (LPAs) Felias and Loera arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Executive Director/Administrator, Corrine Bianco, and 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, "Staff does not ensure communication is provided to resident's responsible party, Resident sustained unexplained fractured hand, Resident sustained unexplained bruising on shoulder, Facility staff restrained resident, Facility staff did not assist resident with dressing as needed, and Facility staff did not meet resident's meal service needs.”

Staff does not ensure communication is provided to residents responsible party – Complainant alleged that resident’s responsible party was not notified that they were out of medication.
Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20240308142252
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: 07/24/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099A

Per staff interviews conducted, facility contacts the pharmacy or primary care physician directly for refills and the responsible party does not transport or order medications. Based on interviews conducted, this allegation is Unsubstantiated.

Resident sustained unexplained hand fracture and unexplained shoulder bruise - LPA received photographs of R1’s hand and shoulder bruise. Per photographs, LPA observed that R1’s hand appeared to be red and swollen. Per Complainant, R1 was observed to have a swollen hand on 11/20/2023 at 5:30PM, and that R1 was taken to the doctor for an x-ray. The x-ray showed that R1 had a pinky fracture. Review of facility documents showed that R1 received an x-ray on 11/24/2023 but there was no additional written documentation. LPA was unable to determine if facility staff observed change in R1’s hand prior to it being observed on 11/20/2023 as there is no additional documentation to review. Per photographs received, LPA observed that R1’s bruise was observed to be yellow in color. Complainant was unable to provide an exact date for R1’s shoulder bruise but stated it was at the end of Summer 2023. Facility notes dated 06/09/2023 stated that R1 had a fall with no visible injury, bruising, or pain reported. R1’s responsible party and primary care physician were notified. Review of Facility documents indicated there was no additional documentation or notes for R1 in July or August 2023 related to observation of bruising or changes in skin condition. Staff interviews conducted stated that bruising can happen after a resident falls or if a resident is very active and moves around a lot. Interviews also stated that facility caregivers would notify the facility medication technicians of any changes. Due to lack of documentation and interviews conducted, LPA is unable to determine if violations occurred, therefore these allegations are Unsubstantiated.

Facility staff restrained resident – LPA received photographs of R1. Per photograph received, it was observed that R1 in a wheelchair. R1 was parallel to the wall, had a sofa chair to the left of the wheelchair, and a TV stand in front of them. LPA also received written documentation from Complainant stating that on 03/03/2024, R1 was observed to be wedged between two cabinets and a table, on 03/04/2024 R1 was observed to be in the corner of the facility dining room, and on 03/08/2024, R1 was observed to be wedged between two non-moveable heavy objects. Interviews with facility staff stated that R1 has shown behaviors where they will continually grab, pull, and push things. Interviews further stated that R1 will sometimes get stuck because they will surround themselves with facility furniture. Facility notes dated 02/22/2024, 03/01/2024, 03/13/2024, 03/15/2024, 03/18/2024, and 04/04/2024 corroborated R1’s behavior. Physician communication notes dated 03/09/2024 and 03/13/2024 showed that facility was communicating with R1’s primary care physician regarding R1’s observed behaviors. During visit, conducted on 07/19/2024, LPA observed that R1 would try and pull items and tables towards them. LPA observed facility staff move R1 away from the furniture or redirect R1 by using their personal objects. Based on document review, interviews conducted, and observations made, LPA is unable to determine if a violation occurred, therefore this allegation is Unsubstantiated.

Continued on LIC9099C

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20240308142252
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: 07/24/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099C

Facility staff does not assist R1 with dressing as needed – Complainant alleged that facility staff are not assisting R1 with their dressing needs because R1 was observed to have their shoes put on the wrong feet and the shoes were tied too tight. LPA received a photograph of R1’s feet which showed that R1’s shoes were on the wrong feet. During visit conducted on 07/19/2024, LPA observed that R1 and the other residents in the facility appeared to be well-groomed and clean. Interviews conducted with staff stated that they have not received any concerns regarding how residents are clothed or dressed. Based on observations made and interviews conducted, LPA is unable to determine if a violation occurred, therefore this allegation is Unsubstantiated.

Facility staff did not meet resident’s meal service needs – Complainant alleged that R1 has lost 40 pounds since moving to the facility. Complainant stated they believe R1’s weight loss is due to facility staff not letting R1 finish their meals and taking it away before they are done. Document review showed that R1 moved to the facility on 01/31/2023. Facility management changed to its current management company on 06/01/2023. Review of R1’s weight log from 06/01/2023 to 03/21/2024 showed that R1’s weight did fluctuate over time. R1’s weight in June 2023 was recorded to be 127.6lbs and their weight in March 2024 was recorded to be 121lbs. LPA is unable to review records for R1 prior to June 2023 due to management change. Per staff interviews, resident weights are to be checked monthly. Residents can take as long as they need to finish their meal if they are slow eaters or require assistance with feeding. If the resident is not hungry during meal time, then the food is placed behind the counter for when they are hungry. During visit on 07/19/2024, LPA made observations during facility’s lunch hour. LPA observed that R1 ate well and that facility staff took R1’s plate away once they were finished. Based on document review, interviews conducted, and observations made, LPA is unable to determine if a violation occurred, therefore this allegation is Unsubstantiated.

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 Executive Director/Administrator, and Health and Wellness Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6