486803645-9-12-2025-21-AS-VBEI-DLSRBE-20250923125238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 09/12/2025
Date Signed: 09/12/2025 01:23:07 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
05/20/2025 and conducted by Evaluator Ali Deniz

COMPLAINT CONTROL NUMBER: 21-AS-20250520084631

FACILITY NAME:	VACAVILLE MEMORY CARE		FACILITY NUMBER:	486803645
ADMINISTRATOR:	CAMILLE BROWN		FACILITY TYPE:	740
ADDRESS:	431 NUT TREE ROAD		TELEPHONE:	(707) 449-1350
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	75	CENSUS: 50	DATE:	09/12/2025
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Administrator, Camille Brown		TIME COMPLETED:	01:59 PM

ALLEGATION(S):

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Resident incontinence care needs are not being met
Facility staff not following resident care plans

INVESTIGATION FINDINGS:

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At approximately 09:40AM, Licensing Program Analyst (LPA) Deniz 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 Department investigated the following allegations “Resident incontinence care needs are not being met and Facility staff not following resident care plans.” Complaint alleged that Staff Member 1 (S1) leaves residents soiled for extended periods during their shift, delays doing their job tasks until bedtime and takes multiple breaks throughout their shift leaving residents unsupervised. Multiple attempts to contact Complainant for more information were unsuccessful. The Department was unable to obtain additional information such as which residents were being left soiled, which residents were being left unattended, and what job tasks were not being completed.

Continued on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025

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-20250520084631

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: 09/12/2025

NARRATIVE

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Continued from LIC9099...

LPAs conducted staff interviews. Interview with S1 denied the allegation that they leave residents unattended. S1 also stated that they complete their job duties and if a task was not completed, it would be relayed to the next shift to complete. S1 stated that they are to check residents every 2 hours or more frequently if the resident requires it. 8 of 12 staff interviews reported seeing an improvement of incontinence care or did not have concerns about resident incontinence care while 4 of 12 staff interviews reported concerns about how often residents were being changed. 10 of 12 staff interviews stated that they haven’t observed or seen S1 or other facility staff leaving the residents unattended while 3 of 12 interviews stated that they have seen or heard of facility staff leaving residents unattended but only 1 of 12 interviews identified S1. 4 of 12 staff interviews reported that certain job tasks such as taking out the garbage or doing the dishes were sometimes not completed while 1 of 12 interviews reported that there were multiple times that they came to work to find that beds were not made, residents not changed, and laundry was not completed. This interview revealed that while these issues did occur before, it was addressed by management and were no longer a concern. None of the interviews conducted identified S1 as being the staff member to not provide incontinence care to residents. 8 of 12 staff interviews reported that they had no concerns with job duties being completed from shift to shift. Interviews further revealed that if a job task was not completed during a shift, it would be relayed to the oncoming shift and it would be the oncoming shift’s responsibility to complete.

Based on interviews conducted, these allegations are 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.

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

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025

LIC9099 (FAS) - (06/04)

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