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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803786
Report Date: 03/17/2026
Date Signed: 03/17/2026 03:57:39 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
12/10/2025 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20251210103016
FACILITY NAME:ISLES ASSISTED LIVING FACILITY, THEFACILITY NUMBER:
486803786
ADMINISTRATOR:MA GRACIA E MANALOFACILITY TYPE:
740
ADDRESS:129 PACER DRIVETELEPHONE:
(707) 254-5444
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: DATE:
03/17/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Suzette TawserTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Resident unlawfully evicted
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso arrived to conduct a complaint inspection, at about 10:30am on 3/17/26, and met with Licensee Suzette Tawser.Currently there are five (5) residents in care; Two (2) residents are on hospice care.
Reporting party alleges "resident unlawfully evicted". LPA reviewed resident R1's records, and reviewed information obtained from interviews with staff, and other related parties. The investigation revealed that Licensee Suzette Tawser notified responsible party that R1's cost of care would cost more money, due to R1's decline and current needs. Licensee notified responsible party of R1 that since they will not pay a higher care cost for R1 that they could not be brought back into care at the facility; Licensee did not allow R1 to return.
Licensee did not provide a required 30-day written notice of eviction to the resident/responsible party, as required by regulation. There was sufficient information otained to support that the violation occurred.
This deficiency will be cited, 87224(a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required, see LIC9099D.
The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Failure to correct deficiencies by due dates, may result in civil penalties being assessed.
Exit interview conducted with Licensee Suzette Tawser.
Appeal Rights Provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
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 4
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
12/10/2025 and conducted by Evaluator Dina Alviso
COMPLAINT CONTROL NUMBER: 21-AS-20251210103016

FACILITY NAME:ISLES ASSISTED LIVING FACILITY, THEFACILITY NUMBER:
486803786
ADMINISTRATOR:MA GRACIA E MANALOFACILITY TYPE:
740
ADDRESS:129 PACER DRIVETELEPHONE:
(707) 254-5444
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: DATE:
03/17/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Suzette TawserTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff neglect resulted in a resident sustaining a pressure injury
Staff did not address a resident's change in condition and seek timely medical
Staff did not follow proper reporting procedures
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso arrived to conduct a complaint inspection, at about 10:30am on 3/17/26, and met with Licensee Suzette Tawser. Currently there are five (5) residents in care; Two (2) residents are on hospice care.

Reporting party alleges "staff neglect resulted in a resident sustaining a pressure injury", "staff did not address a resident's change in condition and seek timely medicail", and "staff did not follow proper reporting procedures". LPA reviewed resident R1's records, reviewed resident's in-home health schedule of visits. R1 was being provided wound care, for a pressure injury, by RNs/Nurses' from Kaiser Home Health. Per record review, there were no progress notes made by Home Health nurses during their home visysts to R1; There was no information obtained from Home Health Nurses, who are licensed medical nurses, of any neglect in care to R1 while residing in the home, per review of records. The Department never received a suspected abuse report, of neglect of R1, reported by the hospital Physicians/Hospital personnel or the Emergency Department regarding neglect of R1 by facility staff.
Continued on LIC9099C..
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
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 4
Control Number 21-AS-20251210103016
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: ISLES ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 486803786
VISIT DATE: 03/17/2026
NARRATIVE
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Per interviews, R1 had some incidents occur while being seen by the Home Health Nurse; The Nurse is a licensed medical professional, and is overseen by a licensed medical Physician, in order to provide in-home nursing care to residents. Per record reviews, there was no report received by the Department of neglect by Home Health Nurses in care to resident R1. Per interviews, staff S1 stated caregivers have called 911 for R1; R1 was assessed by the ER responders, and R1 was not taken to the hospital. R1 was able to speak with ER responders. R1 remained in the facility both times. Staff reported they contacted responsible party as required, and reported to licensing. There is no medical documentation from medical physicians stating an identified individual/individuals being the cause of resident's health concerns and/or diagnosis, per ecord reviews and/or provided by the reporting party. There was no information obtained to support the alleged violations had occurred,

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations "staff neglect resulted in a resident sustaining a pressure injury", "staff did not address a resident's change in condition and seek timely medicall", and "staff did not follow proper reporting procedures". are Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies cited.
Exit interview was conducted with the Licensee Suzette Tawser.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20251210103016
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: ISLES ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 486803786
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2026
Section Cited
CCR
87224(a)
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87224(a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required
This requirement was not met as evidenced by: Licensee notified responsible party of R1 that since they will not pay a higher care cost for R1 that they could not be brought back into care at the facility;

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Licensee/Administrator to submit a written self certification that they have reviewed Eviction Procedures-87224, stating their understanding of this regulation. Submit a plan of future compliance with this regulation. POC due 3/23/26.
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Licensee did not allow R1 to return. Licensee did not provide a required 30-day written notice of eviction to the resident/responsible party, as required by regulation. This is a risk to residents' personal rights.
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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: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4