216804010-6-15-2026-21-AS-VBEI-DVRPCB-20260707111136

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804010
Report Date: 06/15/2026
Date Signed: 06/15/2026 02:48:54 PM

Unsubstantiated

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
03/16/2026 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20260316100024

FACILITY NAME:	VINCENT, THE		FACILITY NUMBER:	216804010
ADMINISTRATOR:	PARI,MANOUCHEHRI		FACILITY TYPE:	740
ADDRESS:	1 LAS GALINAS AVE		TELEPHONE:	(628) 336-1400
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	126	CENSUS: 85	DATE:	06/15/2026
		UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Executive Director, Maria Cortes		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained an injury due to staff neglect
Staff did not seek timely medical attention for a resident

INVESTIGATION FINDINGS:

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At approximately 8:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegations. Executive Director, Maria Cortes, arrived during visit at approximately 9:00AM.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, "Resident sustained injury due to staff neglect, and Staff did not seek timely medical attention for a resident." Complaint alleged that there was a delay in Resident 1's (R1's) care after they had a fall. Per report, R1 was taken to the hospital on 03/12/2026, where they were diagnosed with a lumbar frature. Report further stated that R1 may have fallen 1-2 weeks prior to their hospitalization but that the fall was unwitnessed by staff and R1 did not report their fall.

Continued on LIC9099

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026

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 3

Control Number 21-AS-20260316100024

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: 06/15/2026

NARRATIVE

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Continued from LIC9099

Review of R1’s medical assessment dated 07/23/2024 stated that R1 had a diagnosis of Osteoporosis and Dementia, was non-ambulatory, and was able to communicate their needs.

Review of R1’s Service Plan dated 02/07/2025 stated that R1 utilized a walker, was able to express pain and communicate effectively. It also stated that R1 was a high risk for falls.

Review of R1’s Service Plan dated 01/22/2026 stated that R1 had mild impairment and had some difficulty communicating or receiving information. It also stated that R1 utilized a walker, was able to express pain and was a low risk for falls.

Review of R1’s Service Plan dated 03/08/2026 stated that R1 had mild impairment, could express pain, and had frequent pain and/or discomfort. It also stated that R1 utilized a walker and was a high risk for falls. This plan also stated that to ease R1’s back pain staff were to provide medication and ensure that R1 could rest, sit in a comfortable position, and avoid standing or walking for too long.

Review of Incident Report dated 03/23/2026, stated that on 03/12/2026, R1 was taken to the hospital by family for lower back and leg pain. Per report, R1 was suspected to have a urinary tract infection (UTI) and was receiving antibiotics as treatment.

Facility documents also showed that facility faxed R1's primary physician on 03/10/2026 to notify them of the un-witnessed fall and that there were no injuries noted for R1.

Interview conducted with Witness 1 (W1) stated that R1 transitioned from the facility’s assisted living to their memory care community in February 2026. Per W1, R1 was experiencing pain prior to transitioning to memory care. W1 was unable to determine if there was a change in how R1 was walking prior to being sent to the hospital. W1 stated that R1 used to use a walker and is currently using a wheelchair while they receives physical therapy to work on their gait.

Interview conducted with Witness 2 (W2) stated that prior to moving to the facility’s memory care, R1 was complaining of back pain. W2 was unable to determine if there was a change in how R1 was walking prior to being sent to the hospital. W2 stated that R1 used to use a walker and is currently using a wheelchair while they receive physical therapy to work on their gait.

Interview conducted with Staff Member 1 (S1) stated that R1 usually used a wheelchair and has a history of asking for pain medication for their back. Per S1, R1 is able to communicate where they have pain and will point to the area.

Review of R1’s caregiver end of shift notes for March 2026 was conducted. Notes for 03/10/2026 – 03/11/2026 did not

Continued on LIC9099C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20260316100024

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: 06/15/2026

NARRATIVE

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Continued from LIC9099C

indicate that R1 was having any issues or was in pain. Note for the morning of 03/12/2026 stated that R1 was going to the hospital.

Review of R1’s progress notes for March 2026 was conducted. The following entries were observed:

· On 03/04/2026, facility notified R1’s family that redness was observed on R1’s lower back, that they complained of pain, and stated they felt like they have a fever. R1 was given medication.

· On 03/05/2026, R1 had a urinary analysis test collected and antibiotics were prescribed.

· On 03/10/2026, R1 was found on the floor by their bed and no injuries were noted.

· R1’s progress notes for 03/10/2026 - 03/11/2026 stated that R1 did not have any issues.

· On 03/12/2026, R1 was taken to the hospital for lower back and leg pain. Per progress note entry, R1 had been experiencing pain for a few days. Note continued to state that a urinary tract infection was suspected and that the facility was later notified that R1 had sustained a lumbar fracture.

R1’s electronic medication authorization record (EMAR) was reviewed. Records showed that on 03/10/2026, 03/11/2026, and 03/12/2026, R1 received PRN “as needed” medication for pain. Records did not state why pain medication was needed for R1 but noted that the pain medication was effective.

Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that a 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.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026

LIC9099 (FAS) - (06/04)

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