486830735-11-12-2021-21-AS-CMAZ-C8ZV4E-20211122150612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486830735
Report Date: 11/12/2021
Date Signed: 11/12/2021 02:37:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2021 and conducted by Evaluator Katrina Walters

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210526113603

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: 47	DATE:	11/12/2021
		UNANNOUNCED	TIME BEGAN:	10:17 AM
MET WITH:	Administrator, Jaime Healer		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Neglect and lack of supervision resulted in residents wandering from facility
Neglect and lack of supervision resulted in resident sustaining injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Katrina Walters arrived unannounced at this facility for the purpose of delivering findings for a complaint investigation regarding the above allegations and was greeted by staff. Administrator, Jaime Healer arrived later.

On May 26, 2021, the Department received a complaint alleging that neglect and lack of supervision resulted in residents wandering from facility and that neglect and lack of supervision resulted in resident sustaining injury.

During the course of the investigation LPA conducted interviews with staff, responsible parties and other outside parties, as well as reviewed Resident records, medical reports/documentation, facility time timesheets, Staff assignment list, incident reports, call log reports, Vacaville Police Department records and the facility records.
Continued on LIC 9099C

Substantiated

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: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

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 4

Control Number 21-AS-20210526113603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VACA VALLEY LIVING A MEMORY CARE COMMUNITY	FACILITY NUMBER: 486830735
	VISIT DATE: 11/12/2021

NARRATIVE

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Continued from 9099

Based on interviews, record reviewed, police reports LPA learned that on 5/19/21, residents (R1) and (R2) eloped from the facilities memory care secured perimeter. Statements from interviews reveal residents were missing for approximately 30 minutes. Staff were alerted by the Vacaville Police Department that both residents were found in the back of the building, and resident R1 had been injured. The police and resident’s medical records indicate that R1 had sustained significant injury and was transported to the emergency room. R2 was returned to the facility. Responsible parties were notified. R1 subsequently declined and passed away 16 days after the incident occurred. Coroner’s report identified the injury R1 sustained on 05/26/2021 as cause of death.

During interviews, with Office Coordinator and 5 of 5 staff interviewed report not hearing delayed egress alarm alerting them that R1 and R2 eloped. Facility’s staff checklist and interviews confirm that medication technician’s are to check door alarms every shift. It was reported during interviews and through record review that the alarm was operational two hours before the residents eloped. Statements from interviews reveal that both residents exited through a delayed egress, which was not operational. Based on statements received, Vacaville Police Department records, resident records and R1’s medical records the allegations are substantiated.

The Department has determined that the allegations that resident R1 sustained injuries due to staff neglect and Neglect and lack of supervision resulted in residents R1 and R2 wandering from facility are Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Continued on 9099 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20210526113603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VACA VALLEY LIVING A MEMORY CARE COMMUNITY	FACILITY NUMBER: 486830735
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/15/2021 Section Cited HSC 1569.269(a)(6)	1 2 3 4 5 6 7	1569.269(a)(6) (a)Residents. .shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs.**Immediate civil penalty of $500.00 was issued today for serious bodily	1 2 3 4 5 6 7	Faciltiy repaired delayed egress doors and implimented secondary door alarms. POC cleared during visit.
	8 9 10 11 12 13 14	injury. **Based on records reviewed & interviews facility didn't comply w/reg above when R1 & R2 eloped from the facility, and R1 sustained injury. Which posed an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20210526113603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VACA VALLEY LIVING A MEMORY CARE COMMUNITY	FACILITY NUMBER: 486830735
	VISIT DATE: 11/12/2021

NARRATIVE

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Continued on 9099 C

An immediate civil penalty in the amount of $500.00 is issued today for the violation of a regulation resulting in bodily injury or illness of a person in care. As a result of client’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code 1569.49(f). At this time, the civil penalty assessment is under review.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC9099 (FAS) - (06/04)

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