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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 01/13/2021
Date Signed: 01/13/2021 05:12:01 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/29/2020 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20201029160033
FACILITY NAME:VILLA CAPRIFACILITY NUMBER:
496802026
ADMINISTRATOR:LIMBERG, STEPHANIEFACILITY TYPE:
740
ADDRESS:1397 FOUNTAINGROVE PKWYTELEPHONE:
(707) 526-9090
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:80CENSUS: DATE:
01/13/2021
UNANNOUNCEDTIME BEGAN:
04:35 PM
MET WITH:Stephanie Limberg-AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to properly assist resident with medications
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alviso conducted a complaint inspection to deliver findings on 1/13/21; LPA met with the Administrator Stephanie Limberg by televisit due to the covid-19 pandemic. LPA reviewed resident (R1) files, medical records/orders, and care plan documentation. LPA conducted interviews with staff, and other related parties regarding this investigation. The investigation revealed that R1 was not able to handle their medications, per resident's Physician, and current medical assessment completed by the Physician; The facility Administrator LVN, and a Home Health worker also assessed the resident by observation, and review of medications with the resident which had revealed the resident was not able to understand and manage their own medications safely. Administrator stated that resident's responsible party was in agreement with having the resident on the medication program. The resident did agree and was put on the facility's medication program. LPA identified through investigation and interviews, reporting party's concern was the resident couldn't handle their own medications safely but stated to the LPA that the facility was not at fault and wanted to only ensure the resident's needs would be met regarding medications. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation, Staff failed to properly assist resident with medications, is Unfounded. We have found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
No deficiencies cited during todays visit.
Exit interviews were conducted.
Administrator will receive a copy of this report from the LPA for signature and retention.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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