216804291-3-10-2026-21-AS-VBEI-DS4UXT-20260312155851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804291
Report Date: 03/10/2026
Date Signed: 03/10/2026 02:43:22 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
12/11/2025 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20251211210006

FACILITY NAME:	VILLA GARDENS		FACILITY NUMBER:	216804291
ADMINISTRATOR:	CAMACLANG, ALBERTINA		FACILITY TYPE:	740
ADDRESS:	25 VILLA AVENUE		TELEPHONE:	(650) 722-3521
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	12	CENSUS: 8	DATE:	03/10/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Staff Member, Nancy Mckee		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff caused injury to resident

INVESTIGATION FINDINGS:

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At approximately 1:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegation and met with Staff Member, Nancy Mckee. Licensee/Administrator, Tina Camaclang, was available by telephone.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, "Staff caused injury to resident." Complaint alleged that Resident 1 (R1) stated that they were hit by a caregiver and was observed to have a bruise under their left eye. Report further stated that R1 could not provide any additional information about the caregiver.

Review of R1's file showed that they are currently receiving hospice and home health services. R1's physician report dated 05/15/2025, stated that R1 has a diagnosis of dementia and is able to communicate
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20251211210006

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 GARDENS	FACILITY NUMBER: 216804291
	VISIT DATE: 03/10/2026

NARRATIVE

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Continued from LIC9099

their needs sometimes due to poor memory. R1's care plan dated 04/23/2025 stated that R1 has confusion and agitation related to their dementia diagnosis.

Review of incident report stated that R1 was observed to have redness and pinkish color under their left eye on 12/08/2025. Facility staff notified R1's hospice agency and responsible party. R1's hospice notes dated 12/09/2025 stated that R1 was observed to have a faded bruise under their left eye, and when showed the bruise, R1 stated "that's nothing." Hospice notes continued to state that R1 did not have any other visible injuries or reports of pain. Review of facility notes indicated that a care conference was held on 12/17/2025 to discuss R1's bruise, behavior, agitation, and review medication.

An interview with the resident was conducted. Interview with R1 did not reveal any additional or new information. Interviews with facility staff were conducted. 3 of 3 facility staff members stated that they have not observed or heard of residents being roughly handled or treated in a rude way by staff.

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 discussed and provided to Staff Member. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

LIC9099 (FAS) - (06/04)

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