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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 07/11/2025
Date Signed: 07/11/2025 04:12:06 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
05/30/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20250530124825
FACILITY NAME:VACAVILLE MEMORY CAREFACILITY NUMBER:
486803645
ADMINISTRATOR:CAMILLE BROWNFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 60DATE:
07/11/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Camille BrownTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Staff did not distribute resident's medication as prescribed
Staff do not provide residents with toiletry supplies
INVESTIGATION FINDINGS:
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At approximately 1:00PM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Administrator, Camille Brown.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff do not provide residents with toiletry supplies, and Staff did not distribute resident's medication as prescribed.”
“Staff do not provide residents with toiletry supplies,” – Complainant alleged that facility staff do not ensure residents are supplied with toilet paper, paper towels, and soap, and further stated that the bathrooms are always out of an item or are never fully stocked. During visit on 06/04/2025, it was observed that 14 out of 15 bathrooms were missing items such as toilet paper, paper towels, or soap. During visit conducted on

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
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 3
Control Number 21-AS-20250530124825
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: VACAVILLE MEMORY CARE
FACILITY NUMBER: 486803645
VISIT DATE: 07/11/2025
NARRATIVE
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Continued from LIC9099

06/19/2025, it was observed that 12 out of 15 bathrooms were missing items such as toilet paper, paper towels, or soap. During visit conducted on 07/11/2025, it was observed that 7 out of 15 bathrooms were missing items such as toilet paper, paper towels, or soap. Based on observations made, this allegation is Substantiated.

“Staff did not distribute resident's medication as prescribed,” – Complainant alleged that R1 was not provided their medication timely, stating that they had to wait 18 hours for their medication. Interview conducted with Staff Member 1 (S1) revealed that there are usually two medication technicians each shift. On 05/15/2025, R1’s medication was delivered to the wrong house. Per S1, if a medication is received for a resident that is in a different home, it should be given to the medication technician that oversees that house and the medication technicians coming in for the next shift are to be informed of any medication received prior to their shift. S1 further stated that they found R1’s medication at the end of their shift on 05/16/2025 and therefore was able to start the medication once the medication was located. Review of R1’s file showed that their medication arrived on 05/15/2025 with instructions to be given three times a day. Review of R1’s Electronic Medication Authorization Record (EMAR) showed that R1 missed their morning dose of medication but received their afternoon and evening dosage on 05/16/2025. Based on observations made and interviews conducted, this allegation is Substantiated.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.



Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250530124825
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: VACAVILLE MEMORY CARE
FACILITY NUMBER: 486803645
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed...(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: based on interviews and record review, Licensee did
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Licensee to submit self certification that training will be conducted for all staff that administer medication by POC due date of 07/12/2025. Training to include the following: Trainer, Date, Topics, Job Role, Staff Names and Signatures. Training to be submitted by POC due date of 07/21/2025.
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not comply with the section cited above and did not ensure that Resident 1’s medication was administered per physician’s orders. This poses an immediate health and safety risk to residents in care.
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Type B
07/21/2025
Section Cited
CCR
87307(a)(3)(D)
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87307 Personal Accommodations and Services:(a)...The following provisions shall apply:(3)Equipment and supplies... for personal care and...adequate hygiene practice shall be readily available...:(D) Hygiene items of general use such as soap and toilet paper. This requirement was not
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Licensee to submit In-service training on replenishing house bathroom supplies. Training to include the following: Trainer, Date, Topics, Job Role, Staff Names and Signatures. Training to be submitted by POC due date of 07/21/2025.
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met as evidenced by: based on observations amde, Licensee did not comply with the section cited above and did not ensure that facility bathrooms were supplied with general hygiene items such as toilet paper, soap, and paper towels. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
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