486804297-5-12-2026-21-AS-BMOS-DUMRVT-20260601132205

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804297
Report Date: 05/12/2026
Date Signed: 05/12/2026 12:40:32 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
03/10/2026 and conducted by Evaluator Star Stevenson

COMPLAINT CONTROL NUMBER: 21-AS-20260310131139

FACILITY NAME:	VACAVILLE VILLAGE SENIOR LIVING		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: 57	DATE:	05/12/2026
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Wellness Director- Elizabeth Aguiar		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Facility does not have adequate staffing to meet resident care need

INVESTIGATION FINDINGS:

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At approximately 10:00 AM, Licensing Program Analyst (LPA) Star Stevenson arrived to deliver findings of a complaint received by Community Care Licensing (CCL) on 03/10/2026 and was greeted by Wellness Director- Elizabeth Aguiar. The complaint alleges that R1, who requires the help of 2 simultaneous caregivers for transfers had the help of just one caregiver on the NOC shift of 03/08/2026 or 03/09/2026 and that staff (S9) had “6 more calls for service while helping R1.” The complainant further stated that Vacaville Village Senior Living (facility) “routinely hire employees who quickly quit and as a result the facility is chronically understaffed.”

Records obtained by CCL indicate that at the time of the complaint the facility had 77 residents, 12 of whom required 2-person assist with Hoyer lift or other transfers, while 12 of the 77 residents were receiving hospice care.

Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

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 3

Control Number 21-AS-20260310131139

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 VILLAGE SENIOR LIVING	FACILITY NUMBER: 486804297
	VISIT DATE: 05/12/2026

NARRATIVE

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Continued from LIC9099
Interviews with S1, S2, S3, S4, S5,S6, S7, S8 all report an established history of new employees being hired and quitting weeks after being hired or never showing up for their first day of work, as well as, a documented history of frequent and/or sudden call-offs where employees do not show up to work without warning, on weekends for example.

Observation of payroll records and staffing schedules revealed that on NOC shift (10:00PM to 6:00 AM) from 03/09/2026 to 03/10/2026 just one (1) Med-Tech and two (2) Caregivers were left to care for Assisted Living residents, including twelve (12) of which required 2-person simultaneous assistance. An interview with S6 indicated that “being down to 1 Med-Tech and 1 Caregiver happens on a week-to-week basis, about 2 days out of 5 and that makes it really bad when getting residents ready for bed, toileting etc”. Separate interviews with S7, and S8 also indicated use of just 1 Med-Tech and 1 Caregiver at times for Assisted Living residents. In addition, an interview with S2 indicated that being down to just one Caregiver and a Med-Tech on NOC shift, “was pretty common, that has happened maybe 10 times in the last month” (mid-February to mid-March 2026)

Finally, a review of call light response time on one day of 03/09/2026 revealed a record of four (4) calls for help requiring more than thirty (30) minutes to respond, twenty-six (26) requiring more than fifteen (15) minutes to respond and thirty (30) requiring more than then (10) minutes to respond.

Based on interviews and record review it appears the facility does not have sufficient staffing; therefore the allegation that Licensee does not ensure facility is adequately staffed to meet residents needs is Substantiated.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

A type B citation for violation of California Code of Regulations (CCR) 87411(a) which requires personnel shall at times be sufficient in numbers…to meet residents needs. (See 9099-D page)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit Interview Conducted.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20260310131139

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 VILLAGE SENIOR LIVING	FACILITY NUMBER: 486804297
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/26/2026 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements - General Facility personnel shall at times be sufficient in numbers, and competent to provide the services necessary to meet resident needs: This requirement is not met as evidenced by: Based on interviews and record review	1 2 3 4 5 6 7	Licensee and Administrator will provide documentation of review of California Code of Regulations (CCR) 87411(a) which requires personnel shall at times be sufficient in numbers…to meet residents needs.
	8 9 10 11 12 13 14	facility did not have staffing in sufficient numbers to provide for care as written in both physican assessments and care plans for 77 residents, 12 of which required 2 person assist.	8 9 10 11 12 13 14	In addition, licensee will identify on-going steps/measures to hire and retain staffing sufficient in numbers to meet residents needs and provide a list of these steps to community care licensing by Plan of Correction due date 05/26/2026
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

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