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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 02:13:39 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
08/11/2021 and conducted by Evaluator Katrina Walters
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210811163257
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:
08:48 AM
MET WITH:Jaime Healer, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not distributing medications as prescribed.




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-20210811163257, regarding the above-mentioned allegations, and met with Administrator, Jaime Healer.

On 8/11/2021, the department received a complaint alleging the following: Staff are not following residents prescribed dietary plan, Staff are not distributing medications as prescribed and that staff are not meeting residents’ hygiene needs. LPA Walters opened the complaint on 8/19/2021. At that time, LPA toured the facility made observations and gathered documentation. In addition to the facility visit, LPA conducted interviews with responsible parties and staff. From this, the following determinations were made:

Report Continued on 9099 C
Substantiated
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 6
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
08/11/2021 and conducted by Evaluator Katrina Walters
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210811163257

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: DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Jaime Healer, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Neglect and lack of supervision resulted in a resident falling.
Staff are not meeting residents incontinence care needs.
Staff are not following residents prescribed dietary plan.
Staff are not meeting residents hygiene needs.
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-20210811163257, regarding the above-mentioned allegations, and met with Administrator, Jaime Healer.

On 8/11/2021, the department received a complaint alleging the following: Neglect and lack of supervision resulted in a resident falling, Staff are not following residents prescribed dietary plan, Staff are not meeting residents hygeine needs and that Staff are not meeting residents incontinence care needs. LPA Walters opened the complaint on 8/19/2021. At that time, LPA toured the facility made observations and gathered documentation. In addition to the facility visit, LPA conducted interviews with responsible parties and staff. From this, the following determinations were made:


Report 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: 2 of 6
Control Number 21-AS-20210811163257
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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Continued from 9099

It was alleged that Staff are not following residents prescribed dietary plan, More specifically, that staff failure to give resident their prescribed dietary plan resulted in resident R2's injury. LPA reviewed incident reports and Resident R2's Physician Report and dietary plan, which did not indicate that the facility did not follow their prescribed plan. In addition, during inspection on 8/19/21 LPA observed resident's dietary plan posted in the kitchen. There were also updated dietary plans printed and in view for dietary staff. Facility Coordinator, Jennifer Ramos, provided LPA with a complete list of all of the resident’s dietary plan. LPA toured the facility during mealtime and observed that resident’s R1, R2, R3 and R4 were given meals and drinks as prescribed within their dietary plan. Therefore, based upon the documents reviewed and statements taken, the allegation is unsubstantiated.


It was alleged that Staff are not meeting residents hygiene needs- LPA toured the facility and made observations. Residents appeared to have proper hygiene. LPA reviewed training records finding that staff were trained in personal care and personal rights. Daily routines, including shower schedules were documented. Staff were assisting residents who were observed to be unclean. Therefore, based upon the documents reviewed and statements taken, the allegation is unsubstantiated.


It was alleged that Staff are not meeting residents incontinence care needs. LPA toured the facility, interviewed staff, and reviewed records and did not find sufficient information proving that the residents incontinence care needs aren't being met. Therefore based upon observation and record review this allegation is unsubstantiated.

Continued on 9099 C
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: 3 of 6
Control Number 21-AS-20210811163257
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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Continued from 9099 C

It was alleged that, Neglect and lack of supervision resulted in resident R6 in falling. LPA reviewed resident R6's Physician report (LIC 602), Needs and Service Plan and incident reports, Emails, gathered Statements from reporting parties and staff. Based on the statements and records reviewed, LPA learned that when resident R6 became an increased fall risk, the facility Administrator, conducted an assessment. It is also documented that Based on the assessment the facility made suggestions to the responsible party and requested an additional assessment from the physician. In addition, the facility increased checks for R6 and offered increased stand by assistance. Therefore based upon statements, record review and observation the allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.
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: 4 of 6
Control Number 21-AS-20210811163257
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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Staff are not distributing medications as prescribed- During facility inspection on 8/19/21, LPA Walters conducted an audit of two of the facility medications carts, reviewed 5 resident’s Medication Assistance Records (MARs) and centrally stored logs. LPA learned that both resident R1 and R2 were not given their medication as prescribed by their physician. (pictures taken) Based on observations, interviews and record review the allegation that staff are not distributing medication as prescribed is substantiated.

Therefore a finding that Staff are not distributing medications as prescribed, is Substantiated.A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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 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: 5 of 6
Control Number 21-AS-20210811163257
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: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2022
Section Cited
CCR
87465(a)(5)
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87465(a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self administered medications when needed.
This requirement is not met as evidenced by:
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Facility Administrator and Staff to conduct audit of medications for four weeks and send results to CCL attention LPA Walters by POC due date 4/1/22. Adminsitrator to conduct first audit and send results to LPA by 3/11/22.
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Based on LPAs record review and observations the faciltiy failed to provide 2 of 5 residents their medications as perscribed by doctor which poses an immediate health and safety risk to resident in care.
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6