486830735-1-26-2023-21-AS-KWAS-CNFUHZ-20230126143646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486830735
Report Date: 01/26/2023
Date Signed: 01/26/2023 02:37:54 PM

Document Has Been Signed on 01/26/2023 02:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 44	DATE:	01/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:52 AM
MET WITH:	Jennier Ramos		TIME COMPLETED:	02:47 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Walters arrived unannounced to conduct an Annual Required inspection and met with Care Coordinator, Jennifer Ramos. The Administrator wasn't present for today's inspection, but was available by phone. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA was screened by receptionist for Covid-19 which included a temperature check and screening questions. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. Facility has additional disposable mask to provide visitors should they not have one. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters at the entrance and throughout the facility to promote hand washing and droplet precaution. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Commonly touched surfaces are disinfected at least twice per day. 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: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VACA VALLEY LIVING A MEMORY CARE COMMUNITY	FACILITY NUMBER: 486830735
	VISIT DATE: 01/26/2023

NARRATIVE

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Facility continues to screen staff and residents and maintains documentation. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment (PPE) and have been fit tested by local public health. Staff vaccine information is stored in each staff's folder. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Facility has submitted their Infection Control Plan and Mitigation Plan.

LPA and JR also discussed a self-reported (SOC 341) Report of Suspected Dependent Adult/ Elder Abuse, that was reported to Community Care Licensing on 1/10/2023, The incident involved a non-staff member (NS1) who was observed being physically aggressive towards resident R1. LPA conducted interviews with staff who witnessed the incident and learned that on 01/10/2023, it was alleged that NS1 physically held down R1. Staff immediately intervened alerted management, who asked NS1 to leave the facility. Management alerted R1's responsible party, Ombudsman and Adult Protective Services. (APS). LPA received copies of NS1's file.

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: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC809 (FAS) - (06/04)

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