486830735-6-14-2022-21-AS-HDBI-CGFQXL-20220718123340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486830735
Report Date: 06/14/2022
Date Signed: 06/14/2022 04:08:51 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/28/2022 and conducted by Evaluator Katrina Walters

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220328110730

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: 42	DATE:	06/14/2022
		UNANNOUNCED	TIME BEGAN:	03:08 PM
MET WITH:	Administrator, Jamie Healer		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Staff neglected to clean resident's maggot infested wound.
Facility staff did not properly supervise residents in care.

INVESTIGATION FINDINGS:

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On this date Licensing Program Analyst (LPA) Walters arrived unannounced for the purpose of delivering the findings for this complaint, regarding the above-mentioned allegations, and met with Administrator, Jaime Healer.

During this investigation, LPAs reviewed resident R1’s: Physician reports LIC 602, discharge forms, home health notes, needs and service appraisal. In addition to reviewing resident’s documentation, LPA made observations and conducted interviews with staff.

Based upon information provided the following determinations were made: The complainant alleged that staff neglected to clean resident's maggot infested wound and that the Facility staff did not properly supervise residents in care.

Continued on 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

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-20220328110730

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VACA VALLEY LIVING A MEMORY CARE COMMUNITY	FACILITY NUMBER: 486830735
	VISIT DATE: 06/14/2022

NARRATIVE

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Records review indicates that resident (R1) was receiving home health care to treat their wound. Record review and Interviews with staff and Care Coordinator, confirm that staff were not performing wound care, and that the only individuals managing wound care for R1 were with the home health agency. Incident reports submitted, indicate that when staff observed changes to R1's wound, their hospitalist was notified. Based upon information obtained there were no violations to regulations.

A finding that the complaint allegation Staff neglected to clean resident's maggot infested wound and that Facility staff did not properly supervise residents in care is found to be unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

LIC9099 (FAS) - (06/04)

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