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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830735
Report Date: 06/14/2022
Date Signed: 06/14/2022 03:56:11 PM


Document Has Been Signed on 06/14/2022 03:56 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:
06/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jamie Healer, AdministratorTIME COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) K. Walters conducted an unannounced case management visit and met with Administrator, Jamie Healer.

The purpose of this visit it to follow up with facility regarding violations to regulations learned during the course of a complaint investigation. LPA learned that Administrator permitted staff S1 to work in the facility without being criminally cleared. In review of the documents received, S1 revealed their criminal history on their job application. Based on application status S1 was subject to criminal record clearance. LPA was able to confirm through the Criminal Background Check System-Guardian, that the facility had not waited for S1's fingerprint clearance to clear prior to allowing them to work in the facility. S1 worked for one day before they were terminated. Per Administrator, they were unclear, and thought that once S1 documentation was submitted, that S1 would be clear to work.

Civil penalty in the total amount of $100.00 was issued today for Staff (S1) not being criminally cleared to work in this facility as required.

Appeal Rights Provided.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Jamie Healer, Administrator, who's signature below confirms receipt of report.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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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Document Has Been Signed on 06/14/2022 03:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2022
Section Cited

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87355 Criminal Record Clearance (e)All individuals... shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Dpt...This requirement is not met as evidenced by:
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Based on LPA observation, record review & interview with Licensee did not ensure to obtain a criminal record clearance for staff S1 prior to work, reside or provide care to residents in care which poses an immediate health, safety and personal rights risk to residents in care. ***Civil Penalty is being assessed for the amount of $100 per day.
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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: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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