496802026-1-31-2024-21-AS-BMOS-D7GUQP-20240724154723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 01/31/2024
Date Signed: 01/31/2024 05:51:25 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
01/29/2024 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240129083327

FACILITY NAME:	VILLA CAPRI		FACILITY NUMBER:	496802026
ADMINISTRATOR:	CORTES, MARIA		FACILITY TYPE:	740
ADDRESS:	1397 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 526-9090
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	80	CENSUS:	DATE:	01/31/2024
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Maria Cortes-Administrator		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff are not changing the resident timely

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 1/31/24 at approximately 3:15pm, and met with Administrator Maria Cortez.

LPA reviewed resident (R1) records; The LPA requested copies of resident records, and facility records. Administrator provided the requested copies to the LPA. The LPA conducted interviews with staff, and other related parties. The investigation revealed that R1 is receiving incontinent care by the facility, it's part of resident's care plan. Health & Wellness (H&W) Director Jennifer Haney stated that facility caregivers are to check on the resident every two hours, and change the resident as needed; The resident has a companion with them for part-time hours, and some of the facility caregivers checked a couple times on the resident, to find the companion had already changed R1. Some of the facility caregivers had stopped checking on R1 due to thinking the resident was being provided incontinent care by the resident's private companion.

The LPA discussed the responsibility of the facility staff providing the care plan services, which include incontinent care needs. The private companion is not responsible for the resident's care plan services, and shouldn't provide the care services.

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: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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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Control Number 21-AS-20240129083327

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: 01/31/2024

NARRATIVE

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Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of "staff are not changing the resident timely" has been substantiated.

Due to the substantiation of the allegation, a citation will be cited today, 87625 Managed Incontinence-(b)(1)(2)(3)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered.Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence, 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: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240129083327

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: 01/31/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/15/2024 Section Cited CCR 87625	1 2 3 4 5 6 7	87625 (b)(1)(2)(3 Managed Incontinence-)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.	1 2 3 4 5 6 7	Licensee to ensure an inservice is conducted with all staff regarding incontinent care services to residents. Submit plan of future compliance with this regulation, ensuring staff are checking on resident and changing resident timely. Submit proof of training. All POC documentation is due 2/15/24.
	8 9 10 11 12 13 14	Health & Wellness (H&W) Director Jennifer Haney stated that facility caregivers are to check on the resident every two hours, and change the resident as needed; The resident has a companion with them for part-time hours, and some of the facility caregivers checked a couple times on the resident, to find the companion had already changed R1. Some of the facility caregivers had stopped checking on R1 due to thinking the resident was being provided incontinent care by the resident's private companion. This is a risk to resident's personal rights.	8 9 10 11 12 13 14
	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: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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