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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830735
Report Date: 04/05/2022
Date Signed: 04/05/2022 05:36:05 PM


Document Has Been Signed on 04/05/2022 05:36 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: 44DATE:
04/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Care Coordinator, Jennifer RamosTIME COMPLETED:
05:47 PM
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Licensing Program Analyst (LPA) Walters arrived unannounced and met with, Care Coordinator, Jennifer Ramos. The Administrator was not present for today’s visit. The purpose of this visit is to follow up on incident reports received in which multiple residents fell. LPA also is following up on an incident involving resident, R1. It was self-reported to Community Care Licensing that R1 complained that they weren’t feeling well. Staff S1 contacted that residents Power of Attorney and requested permission prior to contacting emergency. Facility Staff waited for Resident’s POA to arrive and take resident to the emergency room. During the visit, LPA gathered resident’s discharge paperwork, Physician Report, and Needs and Service Appraisal.

At approximately 10:20 AM during tour with Care Coordinator, LPA observed that there was 1 activity staff (S2) providing supervision for 20 residents. Per record review, staff and Administrator 8 of those residents are a fall risk and require standby by assistance. LPA and Care Coordinator discussed having additional staff present to provide care and supervision for residents who are a fall risk.

At approximately 10:30 AM LPA and JR observed resident R2 sitting outside on the patio with an assisted walking device. Per JR, R2 was not a fall risk and has no trouble ambulating throughout facility. LPA reviewed R1’s Physician Report and Needs and Service, Home Health Notes and Service Plan. Through record review which indicates that R2 requires standby assist and that they’re a fall risk. Per JR, they will contact their Physician to have his plan updated.

LPA and Care Coordinator discussed monitoring residents for falls, and maintaining staffing in areas where residents who require assistance are congregating. LPA’s findings during this visit will require additional follow up with facility. There were no deficiencies cited during this visit.

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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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