<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486830735
Report Date: 09/26/2025
Date Signed: 09/26/2025 10:41:08 AM

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
05/28/2025 and conducted by Evaluator Jill Nakagawa
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250528093528
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: 42DATE:
09/26/2025
UNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Jamie Healer, AdministratorTIME COMPLETED:
10:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not follow reporting protocol with responsible party
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On September 26, 2025 Licensing Program Analyst (LPA) Nakagawa arrived unannounced to continue the investigation regarding the above allegation and to deliver findings. LPA met with Administrator Jamie Healer.
The complaint alleges that Staff did not follow reporting protocol with responsible party regarding resident (R1). The reporting party stated that staff did inform the responsible party verbally about incidents occurring on 5/11/25 and 5/20/25 but did not provide a written incident report. LPA verified that incident reports were filed with CCL within 7 days of occurrence.

(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
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
Control Number 21-AS-20250528093528
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: 09/26/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continued from 9099)

LPA conducted an interview with S1 who verified by email, that verbal notification was given to the responsible party but a written copy was not given due to the report including information of another resident. LPA notes that this confidential information could have been redacted and a copy of the Incident Report given to the responsible party of R1. Based on LPA's interviews conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8).
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 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
05/28/2025 and conducted by Evaluator Jill Nakagawa
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250528093528

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: 42DATE:
09/26/2025
UNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Jamie Healer, AdministratorTIME COMPLETED:
10:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not maintain facility sanitary
Staff did not provide resident with housekeeping service
Staff did not assist resident with grooming
Staff did not follow resident's care plan
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On September 26, 2025 Licensing Program Analyst (LPA) Nakagawa arrived unannounced to continue the investigation regarding the above allegations and to deliver findings. LPA met with Administrator Jamie Healer.

The complaint alleges that Staff did not maintain a facility sanitary and Staff did not provide resident with housekeeping service. The reporting party (RP) stated that on 5/11/2025, they observed clothes all over resident R1’s room and dried feces on R1’s floor. RP stated “that on 5/11/2025, they asked staff to clean up the feces from the floor. However staff stated that the feces could not be cleaned up because "the person that cleans it up is not here."
(Continued on 9099-C)



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20250528093528
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: 09/26/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099-A

Licensing Program Analyst (LPA) Nakagawa interviewed RP who stated they brought in cleaning supplies and cleaned the floor up as staff stated they were unable to clean the floor. LPA spoke with S1 who stated staff informed S1 of the issue and that staff did clean the area when it occurred on 5/11/2025. S1 reported the maintenance crew attended the area again on 5/12 /25 in the morning using the carpet cleaning machine. Photos submitted show clothing on the floor of the room but there is no indication of how long clothing was there and does not provide substantial evidence that the facility was not maintained to be sanitary. LPAs Nakagawa and Cuadra inspected the facility on 06/03/25, 8/22/25 and 9/18/2025 and found the facility clean and sanitary. LPA Nakagawa conducted interviews with 4 staff and 2 family and found that 6 out of 6 found the facility to be clean and sanitary. Based on interviews conducted and photos received the allegations that Staff did not maintain a facility sanitary and Staff did not provide resident housekeeping service are unsubstantiated. Although the allegations may have occurred there is not enough evidence to substantiate the allegations therefore the allegations are unsubstantiated.

The complaint alleges that Staff do not follow resident’s care plan. The complainant states that staff did not follow R1’s care plan and that for three days, staff had R1’s personal care items locked away in a cabinet in the bathroom. RP stated that on 5/11/2025, they observed that R1 had worn socks for three days, hair was a mess, teeth were not brushed and R1 was not wearing their hearing aids. RP stated that R1 had worn socks for so long legs were swollen. RP stated that R1 had to wear compression socks to resolve the matter. RP stated that staff did not take off R1’s hearing aids at night per instructions in his care plan, resulting in R1’s hearing aids becoming lost underneath his bed.

(Continued on 9099-C2)

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20250528093528
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: 09/26/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continued from 9099-C)

LPA reviewed the ADL Care Sheet which states that R1 received a bed bath on 5/9 and 5/12 by hospice and 5/15, 5/19, 5/22 and 5/25 during the AM shift by either facility care staff or hospice care. It is documented that teeth were brushed in the AM and PM by care staff. Swelling of legs is mentioned on the Intake Sheet dated 5/8/2025 (the date R1 moved into the facility) and on the Shower Sheet on 5/9/2025. Hospice attended R1 regularly and did not mention any signs or symptoms of pain or swelling until 5/15/2025 when Ted Hose were prescribed to manage the swelling. LPA’s review of care plan shows that care staff were to remove hearing aids each night. Responsible party stated that hearing aids were found under the bed on three occasions. LPA conducted interviews with care staff regarding hearing aid care. 4 of 4 staff verified that hearing aid care and maintenance is regularly conducted during AM and PM care and it is documented in the MAR. Based on LPA’s interviews conducted and record review the allegation is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence to substantiate the allegation therefore the allegation that Staff did not follow resident’s care plan is unsubstantiated.

Report reviewed with Administrator.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20250528093528
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: 09/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2025
Section Cited
CCR
87211(a)(1)(D)
1
2
3
4
5
6
7
87211(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident....(D)Any incident......of any resident., This requirement has not been met as evidenced by:
1
2
3
4
5
6
7
Administrator has provided a redacted copy of requested Incident Reports to responsible party of R1 and to CCL by 9/19/2025.
8
9
10
11
12
13
14
Based on statement of S1staff did not provide a written Incident Report to Responsible Party. This posed a potential risk to the health, safety or personal rights to persons 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6