486804297-2-5-2026-21-AS-BMOS-DR7R83-20260211114716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804297
Report Date: 02/05/2026
Date Signed: 02/05/2026 12:18:27 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
01/20/2026 and conducted by Evaluator Star Stevenson

COMPLAINT CONTROL NUMBER: 21-AS-20260120091821

FACILITY NAME:	VACAVILLE SENIOR ASSISTED LIVING, LLC		FACILITY NUMBER:	486804297
ADMINISTRATOR:	SAMANIEGO, AGUSTIN		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(323) 902-6000
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	160	CENSUS: 78	DATE:	02/05/2026
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator Agustin Samaniego		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff not following care plan when assisting resident with ADLs

INVESTIGATION FINDINGS:

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At approximately 11:45 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver complaint findings for a compliant received by the department on 01/20/2026 in which it was alleged that staff were not following the care plan when assisting a resident (R1) with ADLs. In the complaint, it was alleged that staff person (S1) had their foot run over with a Hoyer Lift while performing a transfer on a resident who requires 2-persons assist with transfers. The complainant indicated, “they were unaware if R1 sustained any injury or whether R1 remained suspended in a (Hoyer Lift) sling during the incident”. The complainant suggested that the “incident reflects a serious safety concern related to improper Hoyer lift use and noncompliance with established two-person assist protocols”

The department obtained records, made observations and conducted interviews. Interviews with witness one (W1), S1, S2 and S3 revealed that use of a Hoyer Lift was not involved in incident that ultimately led to the foot of S1 being run over and that, in fact it was the main wheel of a power wheelchair that ran over S1’s foot. Furthermore, a review or R1’s Physician Report (LIC602) indicates both, “Wheelchair dependent” and “assistance to move” (with a wheelchair).
Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

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-20260120091821

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 SENIOR ASSISTED LIVING, LLC	FACILITY NUMBER: 486804297
	VISIT DATE: 02/05/2026

NARRATIVE

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Continued from LIC9099
Interviews with S1, S3 and W1 revealed a lack of clarity about who ultimately pressed the joystick of the power wheelchair to run S1’s foot, but an interview with W1 indicated that family made several attempts to fix the joystick control of the wheelchair themselves, noting that the control joystick was loose and that the company that provided the wheelchair had been “called multiple times to fix it” and that the family of R1 was considering getting a new power wheelchair for R1. W1 also indicated that the family wanted to remove the power wheelchair from the facility but then R1 became hospitalized for a separate issue, noting that a manual wheelchair for use continued to be in R1’s room.

Because R1 was noted to be “wheelchair dependent” and needed, “assistance to move” (the wheelchair) by Physician’s Report and because a Hoyer Lift transfer was not involved in the incident, the allegation of “Staff not following care plan when assisting residents with ADLs” is UNSUBSTAINTIATED.

A finding of unsubstantiated means, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

LIC9099 (FAS) - (06/04)

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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
01/20/2026 and conducted by Evaluator Star Stevenson

COMPLAINT CONTROL NUMBER: 21-AS-20260120091821

FACILITY NAME:	VACAVILLE SENIOR ASSISTED LIVING, LLC		FACILITY NUMBER:	486804297
ADMINISTRATOR:	SAMANIEGO, AGUSTIN		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(323) 902-6000
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	160	CENSUS: 78	DATE:	02/05/2026
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator-Agustin Samaniego		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff violated residents personal rights

INVESTIGATION FINDINGS:

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At approximately 11:45 AM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver complaint findings of a complaint received by the department on 01/20/2026. In the complaint, it was alleged that staff violated the personal rights of Resident (R1). The complaint alleged that staff person (S1), in performing a Hoyer lift transfer with R1 had their foot run over with a Hoyer Lift while performing a transfer that required two-persons assist. The complainant indicated, “they were unaware if R1 sustained any injury or whether R1 remained suspended (in a Hoyer Lift) sling during the incident” and “the location and condition of R1 at the moment was unclear”

The department obtained records, made observations and conducted interviews. Interviews with W1, S1, S2 and S3 revealed that use of a Hoyer Lift was not involved in incident that ultimately led to the foot of S1 being run over and that R1 was never injured or suspended for a prolonged time in a Hoyer lift sling during the incident. It is for these reason, the Department has found the complaint of a personal rights violation as UNFOUNDED.
A finding of UNFOUNDED means the allegation was false, could not have happened and/or is without a reasonable basis.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

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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