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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 07/16/2026
Date Signed: 07/16/2026 03:06:25 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
04/17/2026 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20260417121342
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: 48DATE:
07/16/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director, Camille BrownTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not seek medical attention to resident.
Staff do not ensure facility is safe, sanitary and in good repair.
Staff does not ensure a safe environment for residents.
Staff does not ensure resident's needs are being met.
Staff are not following food service regulations.
Staff are not following reporting requirements.
Staff are not following infection control protocols.
INVESTIGATION FINDINGS:
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At approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to continue a complaint Investigation and delivered the findings regarding the above allegation and met with Executive Director, 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 did not seek medical attention to resident, Staff do not ensure facility is safe, sanitary and in good repair, Staff does not ensure a safe environment for residents, Staff does not ensure resident's needs are being met, Staff are not following food service regulations, Staff are not following reporting requirements, and Staff are not following infection control protocols.”

The complainant was anonymous, and LPA was unable to obtain additional information regarding the reported concerns. LPA conducted unannounced complaint visits on 04/23/2026, 05/29/2026, and 06/30/2026.
Continued on LIC9099-C page...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
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 5
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
04/17/2026 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20260417121342

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: DATE:
07/16/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director, Camille BrownTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff are mismanaging residents' medications.
INVESTIGATION FINDINGS:
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At approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to continue a complaint Investigation and delivered the findings regarding the above allegation and met with Executive Director, Camille Brown.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff are mismanaging residents' medications.”

The complaint alleged that staff were mismanaging residents' medications, including failing to administer medications as prescribed and failing to ensure medications were available for administration.
LPA conducted unannounced complaint visits on 04/23/2026, 05/29/2026, and 06/30/2026.

Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20260417121342
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: 07/16/2026
NARRATIVE
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Continued from LIC9099-A page...

During the investigation, LPA reviewed facility records, including incident reports, medication records, and interviewed staff. The investigation revealed that the facility self-reported two medication errors. On 03/16/2026, the facility submitted an incident report documenting that a resident received the wrong medication. A second self-reported incident dated 05/22/2026 documented another medication administration error in which staff administered an incorrect medication during the medication pass.



Based on the facility's self-reported incident reports, staff interviews, and records reviewed, LPA obtained sufficient evidence to support the allegation that staff mismanaged residents' medications. Therefore, this 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.

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: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20260417121342
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: 07/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/17/2026
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 by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by:
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Executive Director Agrees to conduct in-service training regarding medication pass and submit proof of self-certification to CCL by plan of correction days 07/17 2026.
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Based on record reviews facility failed to administer correct medication during the medication pass. This poses immediate health and safety concerns for the 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.
SUPERVISOR'S NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20260417121342
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: 07/16/2026
NARRATIVE
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Continued from LIC9099 page...

During the investigation, LPA interviewed staff, reviewed available records, and toured the facility, including resident rooms, common areas, bathrooms, laundry rooms, kitchens, and outdoor areas. LPA observed the facility to be clean, organized, and maintained at a comfortable temperature. The laundry rooms and bathrooms appeared clean and in good repair, and LPA did not observe conditions consistent with the allegations of unsanitary living conditions or infection control concerns.

LPA reviewed the facility’s reporting practices related to resident incidents. Administrator stated that emergency medical services are contacted as needed based on the nature and severity of an incident. Regarding the reported resident incident, the facility determined that the event did not meet the criteria for an elopement, as the resident remained within the secured facility grounds and did not exit the facility. The facility documented the event through an internal note, and LPA did not find evidence that the incident resulted in a reportable injury or required additional medical intervention.

LPA also reviewed the facility’s practices for meeting residents’ care needs. Staff reported that resident care checks are conducted at least every two hours and additionally as needed, including assistance with personal care and incontinence care. During facility tours, LPA observed residents to be appropriately cared for and did not observe residents who appeared neglected, soiled, or without necessary assistance.
LPA did not observe unlabeled food, expired food, or food being improperly stored. Staff explained that all meals are prepared in the facility’s commercial kitchen, delivered to each house at mealtimes, and any leftovers are returned to the main kitchen after meals.

Based on interviews, observations, and records reviewed, LPA did not obtain sufficient evidence to support the allegations that staff failed to seek medical attention for residents, maintain a safe and sanitary facility, provide adequate supervision and care, follow food service regulations, comply with reporting requirements, or follow infection control protocols. Therefore, these allegations are Unsubstantiated. A finding of Unsubstantiated means that although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

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: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5