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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830735
Report Date: 06/06/2022
Date Signed: 06/06/2022 03:15:40 PM


Document Has Been Signed on 06/06/2022 03:15 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: 41DATE:
06/06/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Jamie HealerTIME COMPLETED:
02:45 PM
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
On 06/06/2022 Licensing Program Analyst (LPA) Walters and Licensing Program Managers (LPMs) Debenedetti and Moellers initiated an informal meeting via Microsoft Teams with Administrator, Jamie Healer, Licensee, Jason Reyes, Care Coordinator, Jennifer Ramos and Joel S. Goldman. The purpose of this meeting is to discuss various areas of concerns. LPA made a subsequent phone call to deliver finalized reports with Administrator, which were e-mailed for signature.

Topics discussed during the call were an increase in falls and what the facility has done to address it, incident reports received and observations, resident needs and service appraisals. Per Administrator the facility has developed a fall assessment checklist in order to reduce the amount of falls occurring at the facility, which also serves as a marker for individuals that may require updates to their care plans.

LPA also advised that there are currently 2 incidents still being reviewed and will follow up with the facility at a later date.

Administrator, Jamie Healer agreed to send LPA a copy of the facilities fall assessment checklist they have implemented used to address falls.

No deficiencies cited during today's report.
Document reviewed with Administrator and signatures on file.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1