486830735-9-13-2021-21-AS-KWAS-C6TSAJ-20210913134225

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486830735
Report Date: 08/19/2021
Date Signed: 09/13/2021 01:42:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	JAMIE HEALER		FACILITY TYPE:	740
ADDRESS:	80 ORANGE TREE CIRCLE		TELEPHONE:	(707) 724-6751
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	60	CENSUS: 48	DATE:	08/19/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:54 AM
MET WITH:	Jennifer Ramos, Care Coordinator		TIME COMPLETED:	02:18 PM

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On 8/19/21 Licensing Program Analyst (LPA) Walters conducted a Case Management inspection with Care Coordinator, Jennifer Ramos. The Administrator was not available for today's visit. This is a residential memory care facility, the current census is 48. There were 6 staff on duty providing care and supervision.

While conducting a complaint inspection, LPA observed the following area of non-compliance: At approximately 10:30 AM while on tour, LPA observed, that the facility exit was obstructed using a ply wood board from the exterior. The ply wood was screwed into the door frame with nails, preventing residents from exiting or opening the exit door. Maintenance Staff, immediately unscrewed the nails. Pictures were taken and will remain on file.

JR, stated that the auditory alarm and delayed egress on the facility exit was malfunctioning, a ply wood board was placed on the exit door, to prevent the alarm, from continuing to sound. JR understands that all EXIT's must be unobstructed. The facilities plan of operation and emergency disaster plan shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering when delayed egress is not functional. JR also understands that all incidents are to be reported to CCL.

Continued on 809-C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
	VISIT DATE: 08/19/2021

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The following deficiencies were observed (see LIC 809D) 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.

A civil penalty for $500.00 was assessed during today's visit.

Due to a computer malfunction all reports from this date were erased from the database, original copies with signatures are on file and this 9099 is just to memorialize in the database the 10 day was completed timely.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/23/2021 Section Cited	1 2 3 4 5 6 7	87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on Observation, Licensee did not comply by obstructing a facility exit, which poses an immediate health, safety or personal rights risk to persons in care.**Immediate Civil Penalty assessed in the amount of $500.]' [	8 9 10 11 12 13 14	Administrator will send proof of inspection to CCL attention LPA Walters.
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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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC809 (FAS) - (06/04)

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