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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830735
Report Date: 11/28/2023
Date Signed: 11/28/2023 02:14:17 PM


Document Has Been Signed on 11/28/2023 02:14 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: 42DATE:
11/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Care Coordinator, Jennifer RamosTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Farhaan Sarangi arrived unannounced at Vaca Valley Living A Memory Care Community for the purpose conducting a Case Management-Incident Inspection. LPA was greeted by Care Coordinator, Jennifer Ramos, and was granted access into the facility.

During this Case Management-Incident inspection, LPA followed-up with an incident that was forwarded to the Regional Office on October 10, 2023. LPA interviewed the Care Coordinator and the resident. LPA toured the facility and found the facility to be clean, at a comfortable temperature with all exits free from obstruction. LPA observed residents engaging in activities during the Case Management-Incident Inspection.

LPA toured Resident #1's room and found the room to be substantial compliance. LPA observed a lower bedframe to assist the resident when the resident is getting up.

No deficiencies were observed or cited during today's Case Management-Incident inspection. Exit interview was conducted and a copy of this report was given to the Care Coordinator, Jennifer Ramos.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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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