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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830735
Report Date: 04/06/2023
Date Signed: 04/06/2023 03:48:46 PM


Document Has Been Signed on 04/06/2023 03:48 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 COMMUNITYFACILITY NUMBER:
486830735
ADMINISTRATOR:JAMIE HEALERFACILITY TYPE:
740
ADDRESS:80 ORANGE TREE CIRCLETELEPHONE:
(707) 724-6751
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:60CENSUS: 49DATE:
04/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jamie Healer, AdministratorTIME COMPLETED:
03:55 PM
NARRATIVE
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LIcensing Program Analyst Jill Nakagawa arrived to conduct a case management visit regarding a resident elopement and met with Administrator Jamie Healer. There are 49 residents at the time of the visit.

LPA conducted a case management regarding elopement of resident R1. On 03/25/23 at approximately 6:12PM resident R1 eloped from facility. Facility's entrance alarm was activated. Staff thought it was activated by another resident who was in the area. Alarm was reset. No headcount of residents was conducted. R1 was found one hour later nearby, unharmed. Resident R1 's Physician’s Report shows resident is unable to leave facility unassisted. R1 was not previously a wander risk. R1 has been re-assessed and facility has updated R1's care plan taking into consideration new behaviors.


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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/06/2023 03:48 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2023
Section Cited

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87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidence by**
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Licensee/Administrator will be reviewing regulation 87705 Care of Persons with Dementia with staff and Licensee. In addition Licensee to send in written plan on how they will meet regulation and meet resident R1's needs. Facility to send in proof of staff training. (Proof provided at time of visit on 04/06/2023)

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***Based on incident report Resident R1 eloped from facility without staff knowledge on 03/25/23. Current medical assessment for resident states resident has a diagnosis of Dementia and is not able to leave facility unassisted, which poses an immediate health, safety risk to residents in care.
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Plan of correction (POC) due date for written statement due 04/06/2023 and proof of staff training due 04/06/2023. POC cleared at the time of visit.

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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2