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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 10/14/2022
Date Signed: 10/14/2022 04:29:08 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
10/10/2022 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20221010112046
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: 59DATE:
10/14/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Stephanie Limberg-AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility sink faucets do not deliver hot water
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, 10/14/22 at approximately 10:15am, and met with Administrator Stephanie Limberg.

LPA reviewed facility records regarding incidents and/or reports regarding the facility's hot water; The LPA conducted interviews with staff and other related parties regarding the hot water incident(s) in resident unit(s). The investigation revealed that the facility has had hot water issues in the recent past, February 2022 & September 2022, that affected a few specific apartments, the hot water was running hot intermittently. These hot water incidents were addressed by the facility; A professional plumbing service company was called, and came out, and inspected and completed any repairs needed regarding each of those incident dates.
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: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
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 3
Control Number 21-AS-20221010112046
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: 10/14/2022
NARRATIVE
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Currently, October 10, 2022, Administrator notified the Licensing office by phone and submitted incident report, of a hot water issue affecting a unit(s) , hot water was being received intermittently. Per records review, the facility Administrator had an evening Professional Plumbing Serviceman come into the facility and inspect the hot water issue. The Plumber identified that the" tempering valve" needs to be replaced, and this part will need to be ordered. The order of this part will take longer than expected due to the part not being available in California. The part will need to be made and than shipped out to the Plumbing Company. The Plumbing Company will contact the facility to schedule the installation of the part once received.

LPA checked various resident rooms hot water temperature, including the unit affected, and all were found to be in compliance, not below 105.F and not higher than 120.F, Per investigation, the hot water issue is affecting a unit, the water gets hot at this time but can run hot intermittently and/or can interrupt the hot water due to the repair needed.

Based on LPA interviews, review of records, and information LPA obtained, the investigation has revealed that the allegation of "facility sink faucets do not deliver hot
water" has been substantiated.

Due to the substantiation of the allegation, a citation, 87303 (e)(2) Maintenance and Operation, will be cited today, see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Exit interview conducted with the Administrator Stephanie Limberg.
Appeal Rights Given.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20221010112046
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: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
10/17/2022
Section Cited
CCR
87303(e)(2)
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87303(e)(2)Maintenance and Operation: Water supplies and plumbing fixtures shall be maintained as follows:Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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POC CLEARED 10/14/2022-BY ADMINISTRATOR ADDRESSING THE HOT WATER ISSUE AS NEEDED AND REQUIRED. Currently, the hot water is running within regulation, and a part has been ordered to replace the "temperature Valve" per last Plumbing inspection service. This will be installed as soon as received.
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This requirement was not met as evidenced by review of records, interviews with staff and other related parties. The hot water has had some incidents of running cold for 15 mins or so before getting warm and running hot intermittently. Currently a unit is affected by this, and Professional Plumber identified a part needing to be replaced. Currently, it is on order and will be installed as soon as received. Hot water may continue to run hot intermittently till repaired. Licensee has reported all hot water incidents. his is a risk to health and safety and/or a personal rights violation to residents in care.
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Licensee to continue to ensure there is a plan in place for hot water issues, as needed, for residents affected and/or provide information of other units that may be available to the resident with no hot water concerns. Ensure communication is made/notification to residents and responsible parties, of hot water issues, including any updates. Licensee to continue to ensure hot water to residents in the facility.
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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: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC9099 (FAS) - (06/04)
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