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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486830735
Report Date: 03/10/2022
Date Signed: 03/10/2022 01:59:01 PM



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
11/04/2021 and conducted by Evaluator Katrina Walters
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20211104132038
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: 47DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Jaime Healer, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff mismanaged resident's medications
INVESTIGATION FINDINGS:
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On this date Licensing Program Analyst (LPA) Walters arrived unannounced for the purpose of delivering the findings for complaint # 21-AS-20211104132038, regarding the above-mentioned allegations, and met with Administrator, Jaime Healer.

On 11/4/2021, the department received a complaint alleging the following: Staff mismanaged resident's medications. LPA Walters opened the complaint on 11/12/2021. At that time, LPA toured the facility made observations, reviewed 5 residents medications documents, and MARs, and gathered documentation. In addition to the facility visit, LPA conducted interviews with responsible parties and staff. From this, the following determinations were made:

Continued on 9099 C

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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 2
Control Number 21-AS-20211104132038
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: 03/10/2022
NARRATIVE
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The allegation alleged that resident R1 was given medication that was not prescribed to them. Through a review of resident medication records, LPA learned that resident R1 was prescribed the medication in question, and the medication was discontinued. LPA reviewed resident records and did not observe any medication errors or that the medication was given to R1. There wasn't insufficient information to prove that the allegation Staff mismanaged resident's medication occurred. LPA observed that all other medication was in order. Therefore the complaint is Unsubstantiated.

A finding that the complaint allegation is unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred.

No deficiencies cited.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2