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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 07/01/2025
Date Signed: 07/01/2025 01:23:08 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/07/2025 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250407104217
FACILITY NAME:VILLA CAPRIFACILITY NUMBER:
496802026
ADMINISTRATOR:CORTES, MARIAFACILITY TYPE:
740
ADDRESS:1397 FOUNTAINGROVE PKWYTELEPHONE:
(707) 526-9090
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:80CENSUS: DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Maria Cortes-AdministratorTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Facility staff are not providing resident's medication dosage as prescribed
Facility staff have not requested required medication refills
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 7/1/2025 at approximately 10:20am, and met with Administrator Maria Cortes.

Reporting party alleges that facility staff are not providing resident's medication dosage as prescribed, and facility staff have not requested required medication refills. The LPA conducted interviews with staff, S1, S2, and interviews with other related parties regarding allegations.

LPA reviewed R1's records. including care plan, medical assessment, medication records, including eye drop medication records, medical documentation/appointment records, and admission documents.

The investigation revealed that resident R1's medications have been provided to R1 as prescribed, and ordered by the Physician, per review of records and staff interviews.

Continued on LIC9099C..
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
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 2
Control Number 21-AS-20250407104217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026
VISIT DATE: 07/01/2025
NARRATIVE
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The medication refills for R1 have been provided to the facility as required by care plan agreements, and recorded as received by facility staff, per medication record reviews. There was differing information obtained during the investigation regarding allegations; There was no information obtained to support that violations had occurred.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "facility staff are not providing resident's medication dosage as prescribed, and facility staff have not requested required medication refills” are Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies cited.
Exit interview was conducted with the Administrator Maria Cortes.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2