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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486830735
Report Date: 08/26/2024
Date Signed: 08/26/2024 03:10:01 PM

Substantiated


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
06/26/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240626094424
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: 33DATE:
08/26/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Nicole Oppold, Administrative AssistantTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff speak inappropriately to residents
INVESTIGATION FINDINGS:
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On 08/26/2024, Licensing Program Analyst (LPA) Nakagawa arrived unannounced for the purpose of delivering findings of a complaint investigation and was greeted by NIcole Oppold, Administrative Assistant . LPA interviewed staff, reviewed records and made observations.

Complaint alleges “Facility staff speak inappropriately to residents”. LPA interviewed 6 staff and discovered that 2 of 6 staff had witnessed other staff yelling or being rude to residents. Interviews with 4 residents found that 2 of the 4 residents had witnessed staff either yelling, being rude or disrespectful to residents in care.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20240626094424
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: 08/26/2024
NARRATIVE
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Continued from 9099....

The allegation a personal rights violation is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.

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.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240626094424
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2024
Section Cited
CCR
87468(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Licensee to submit plans for staff training of regulation CCR 87468 by 08/27/2024. Plans to include date, materials to be used. Proof of training to be
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This requirement was not met as evidence by:**
Based on interviews with multiple staff and residents on 07/03/2024, review of records, staff had inappropriately responded to residents. This is an immediate personal rights risk to residents in care.
Licensee failed to ensure client personal rights were protected.
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submitted to CCL by 08/05/2024, including staff sign-in sheet
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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: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3