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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486830735
Report Date: 01/06/2021
Date Signed: 01/06/2021 11:37:40 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20201214142421
FACILITY NAME:VACA VALLEY LIVING A MEMORY CARE COMMUNITYFACILITY NUMBER:
486830735
ADMINISTRATOR:JAMIE HEALERFACILITY TYPE:
740
ADDRESS:80 ORANGE TREE CIRCLETELEPHONE:
(707) 724-6751
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:60CENSUS: 47DATE:
01/06/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jennifer RamosTIME COMPLETED:
09:30 PM
ALLEGATION(S):
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Staff member forged other staff members' signatures on medical documents
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert met with J Ramos this date for the purpose of delivering findings on this complaint allegation. The visit was conducted via tele-visit due to the COVID-19 precautions. LPA did not physically present at the site. It has been alleged that staff signatures have been forged on facility medical records. This Department has investigated the allegation by conducting interviews with witnessess/staff and reviewing and obtaining documents. The following determinations have been made: copy of MAR sheet provided this Department does not match the one currently in facility binder(Exhibit B); with one exception, all signatures on Mar sheet (Exhibit A) appear to be written by the same person; facility Plan of Operation requires "all documentation will be accompanied by a signature of the trained staff that passed the medication. This includes any type of medication pass;" Administration reports that the failure to document medication passes correctly were mistakes and clericle in nature. Based upon the documents reviewed and statements taken, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2021
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 2
Control Number 21-AS-20201214142421
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VACA VALLEY LIVING A MEMORY CARE COMMUNITY
FACILITY NUMBER: 486830735
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2021
Section Cited
CCR
87208(a)
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PLAN OF OPERATION. Each facility shall have and maintain a current, written definitive plan of operation. Based upon interviews taken and documents reviewed, this requirement has not been met in that facility medical records exhibits A and B show forged and missing staff signatures.
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Management has scheduled comprehensive retraining for all staff handling medication administration and will submit to CCL proof of training by POC date in order to clear the deficiency.
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 Facility's Plan of Operation requires all documentation to be signed by the staff that passed the medication which includes any type of medication. This poses a potential risk to the health of 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.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2