496802026-8-1-2023-21-AS-VBEI-CYHREY-20231214115819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 08/01/2023
Date Signed: 08/01/2023 05:26:10 PM

Unfounded

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
07/12/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230712092251

FACILITY NAME:	VILLA CAPRI		FACILITY NUMBER:	496802026
ADMINISTRATOR:	LIMBERG, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	1397 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 526-9090
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	80	CENSUS:	DATE:	08/01/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Maria Cortez-Administrator		TIME COMPLETED:	05:35 PM

ALLEGATION(S):

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Staff are not following physician's orders/instructions regarding resident's medications.
Facility is not following the Admission's Agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 8/1/23 at approximately 1:45pm, and met with Administrator Maria Cortez. LPA reviewed resident(R1) records, including medical and medication documentation. LPA conducted interviews with staff, and other related parties. The investigation revealed that R1 didn't have a Dr's Order regarding their handling own medication(s); There was no record on file of a self-administration evaluation having been completed on R1 which is part of the process in determining if a resident can handle own over the counter(OTC)medications. These procedures are part of the facility's medication policies. On 6/30/23, facility staff collected all OTC medications from R1 and handled these medications with all the other medications facility assists R1 with. Administrator ensured an evaluation was completed, along with obtaining a Dr's Order stating the resident can handle the OTC medications.
Continued on LIC9099C..

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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 6

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
07/12/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230712092251

FACILITY NAME:	VILLA CAPRI		FACILITY NUMBER:	496802026
ADMINISTRATOR:	LIMBERG, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	1397 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 526-9090
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	80	CENSUS:	DATE:	08/01/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Maria Cortez-Administrator		TIME COMPLETED:	05:35 PM

ALLEGATION(S):

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Staff yell at residents, and speak inappropriately to them.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 8/1/23 at approximately 1:45pm, and met with Administrator Maria Cortez. LPA reviewed resident(R1) records, including medical and medication documentation. LPA conducted interviews with staff, and other related parties. The investigation revealed that staff interviewed denied yelling at residents or speaking inappropriately to the residents. Per staff records reviewed, staff had required trainings. The investigation found that there was different information from interviews conducted and information provided by the reporting party. There was no information obtained to support a violation had occurred. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "Staff yell at residents, and speak inappropriately to them" is 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
07/12/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230712092251

FACILITY NAME:	VILLA CAPRI		FACILITY NUMBER:	496802026
ADMINISTRATOR:	LIMBERG, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	1397 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 526-9090
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	80	CENSUS:	DATE:	08/01/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Maria Cortez-Administrator		TIME COMPLETED:	05:35 PM

ALLEGATION(S):

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Staff do not respond to residents' requests for assistance in a timely manner.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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 6

Control Number 21-AS-20230712092251

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: 08/01/2023

NARRATIVE

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R1 called for a medication technician on their own, and reported their long wait for assistance. Administration staff stated they conducted interviews and reviewed information obtained from parties that had reported to them prior to the LPA's visit. Per record reviews and interviews, staff(S3) was spoken to, and provided information regarding their job duties/customer service, regulation requirements, and provided additional training to complete. LPA requested copies and received them from the Administrator.

Based on LPA interviews, review of records, and information LPA obtained, the investigation has revealed that the allegation of "Staff do not respond to residents' requests for assistance in a timely manner" is substantiated.

Due to the substantiation of the allegation, a citation, 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities- In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 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. 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.

Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.
Appeal Rights Given.
Exit interview conducted with the Administrator Maria Cortez.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 21-AS-20230712092251

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: 08/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/18/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	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.	1 2 3 4 5 6 7	Licensee/Administrator to have an in-service with all staff regarding "residents personal rights" and that staff are to not violate these rights at any time. Proof of training to include, Trainer, Topics, Date/Time Spent and Attendees.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Per investigation, Resident waited an hour for assistance after requesting a med-tech, R1 had requested S3/staff to call for a med-tech for them. S3 never called for a med-tech. R1 called on their own for a med-tech to assist them after waiting an hour. This is a risk to residents personal rights and/or a risk to resident's health& safety.	8 9 10 11 12 13 14	Submit plan of correction, and proof of training by 8/18/23. POC due 8/18/23.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 21-AS-20230712092251

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: 08/01/2023

NARRATIVE

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R1 was provided the specific OTC medications on 7/13/23 to handle on their own, per record review. Admission agreement was reviewed. No information obtained to support a violation had occurred.

Per record review, all medications are being provided per Dr's Orders. There was no information obtained to support that the facility is not following resident's(R1) Dr's orders or that the facility is not following R1's admission agreement.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations, "Staff are not following physician's orders/instructions regarding resident's medications" and "Facility is not following the Admission's Agreement" are Unfounded. We have found that the complaint allegation(s) was Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies cited.
Exit interview was conducted with the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC9099 (FAS) - (06/04)

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