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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 09/05/2023
Date Signed: 09/05/2023 05:20:46 PM

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
07/05/2023 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230705112138
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:
09/05/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria Cortes-AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff are not ensuring that resident(s) receive their medication(s) timely.
Staff did not ensure that resident's call button was operable and/or answered timely


INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Alviso conducted a complaint inspection, on 9/5/23 at approximately 9:30am, and met with Administrator Maria Cortes.

LPA reviewed facility records, resident records, R1 & R2, including medical documents, and medication records. LPA conducted interviews with six(6) staff, and other related parties. The investigation revealed that the facility didn't refill resident's medication in a timely manner, and resident's responsible party had to go buy the medication on 4/5/23 for the resident.

The medication had no more capsules on 4/5 and had only been reordered 4/3, per review of records. Faclity didn't follow their medication policy and procedures regarding resdent medication refills, and ensuring residents have all Physician ordered medication available to them as needed.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
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 5
Control Number 21-AS-20230705112138
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: VILLA CAPRI
FACILITY NUMBER: 496802026
VISIT DATE: 09/05/2023
NARRATIVE
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Based on LPA interviews with staff, interviews with other related parties, review of records, and information LPA obtained, the investigation has revealed that the allegation of "Staff are not ensuring that resident(s) receive their medication(s) timely" is substantiated.
Due to the substantiation of the allegation, a citation, 87465(a)(4) Incidental Medical and Dental Care- The licensee shall assist residents with self- administered medications as needed, will be cited today. Deficiency on LIC9099D.

Per LPA's review of call log records, interviews with two(2)staff, and interviews with other related parties, the investigation revealed that R2 had used the call bell/pendant on 5/20/23 at 3:36am, and it rang staff five(5) times, there was no response by medication technician until twenty-four(24) minutes after resident rang for assistance. R2 used their call bell/pendant on 6/27/23 at 5:34pm, and it rang staff six(6) times, there was no response by caregiver until twenty-five(25) minutes after resident rang for assistance.

Based on LPA interviews with staff, interviews with other related parties, review of records, and information LPA obtained, the investigation has revealed that the allegation of "Staff did not ensure that resident's call button was operable and/or answered timely" is substantiated.
Due to the substantiation of the allegation, a citation, 87468.2(a)(4) Additional Personal Rights of Residents- In addition to the rights in Section 87468.1, Personal Rights of Residents: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers qualifications, and competency to meet their needs. this will be cited today. Deficiency on LIC9099D.

The preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Appeal Rights Provided to the Administrator.
Exit interview conducted with the Administrator Maria Cortes.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20230705112138
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: VILLA CAPRI
FACILITY NUMBER: 496802026
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2023
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care- The licensee shall assist residents with self- administered medications as needed. This requirement was not met as evidenced by: The LPA's review of records, interviews, investigation revealed that the facility didn't refill resident's medication in a
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DEFICIENCY CLEARED TODAY-9/5/23. LICENSEE HELD AN IN-SERVICE TRAINING ON FACILITY'S MEDICATION POLICY & PROCEDURES, ON 7/13/23, REGARDING THE INCIDENT OF R1'S MEDICATION NOT BEING FILLED
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timely manner, Medication was ordered 4/3, and resident's responsible party had to go buy the medication on 4/5/23 for the resident. This is a health and safety risk and/or a personal rights risk to residents in care.
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TIMELY FOR THE RESIDENT AS REQUESTED/REQUIRED. POC CLEARED.
Type B
09/15/2023
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents- In addition to the rights in Section 87468.1, Personal Rights of Residents: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Per LPA's review of
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Licensee to ensure all staff are responding to resident call bell/pendants in a timely manner when ringing for assistance. Hold an in-service training with all staff on facility's signal system, Call Bell/Pendant Policy and Procedures. Submit plan of correction , and proof of training by 9/15/23.
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records, interviews with staff, and other related parties, resident rang call bell/pendant for assistance on 5/20, with no response till 24 minutes later; & 6/27 resident rang call bell/pendant for assistance and no response till 25 minutes later. This is a risk to resident health & safety and/or personal rights. Civil Penalty assessed in the amount of $250.see LIC421FC.
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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: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
07/05/2023 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230705112138

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:
09/05/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria Cortes-AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility laundry services are unsanitary.
Staff left resident in soiled items for an extended period of time.
Staff are not providing a safe environment for resident(s) in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Alviso conducted a complaint inspection, on 9/5/23 at approximately 9:30am, and met with Administrator Maria Cortes.

LPA reviewed facility records, resident records, including facility policy and procedures on resident laundry, incontinent care, and addressing residents incidents, including resident behaviors; LPA obtained copies of policies and procedures. LPA conducted interviews with six(6) staff, and other related parties.

The investigation revealed that facility policy is that all resident laundry is washed separately. Incontinent residents are toileted if they are able, and incontinent residents are checked every two hours to clean and change if needed. Per interviews with staff, Incontinent residents are cleaned and changed by staff
in-between the two hour check if observed by staff, and as needed.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20230705112138
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: VILLA CAPRI
FACILITY NUMBER: 496802026
VISIT DATE: 09/05/2023
NARRATIVE
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Per record reviews of resident reports, and staff interviews, incidents where a resident may be having behaviors, aggression and/or two residents having an altercation, are handled by staff redirecting residents as needed. Incidents are reported to Supervisors who will ensure follow-up as needed. Residents are monitored as needed.

There was no information obtained to support violations had occurred regarding the allegations. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "Facility laundry services are unsanitary, Staff left resident in soiled items for an extended period of time, Staff are not providing a safe environment for resident(s) in care. " are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies cited.
Exit interview was conducted with the Administrator Maria Cortes.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5