496802026-3-5-2024-21-AS-BMOS-D7GUQN-20240724154723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 03/05/2024
Date Signed: 03/05/2024 01:54:54 PM

Unsubstantiated

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: 62	DATE:	03/05/2024
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Maria Cortes-Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff are not following Physicians orders

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 3/5/24 at approximately 9:20am, and met with Administrator Maria Cortez.

LPA reviewed resident (R1) records and facility records.The LPA reviewed MAR records that document medications residents are assisted with; The MARs also shows days medications were provided, including any refusal of medications and/or why a medication was not provided to a resident.

The LPA reviewed resident R1's care plan, medication records, including Dr's Orders. The LPA conducted interviews with staff, and other related parties regarding the allegation.

The Investigation revealed that medication orders are provided as prescribed by the Physician to the resident. There is a supplement shake that per review of records, R1 refused at times, and this is documented in records.
Continued on LIC9099C...

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: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

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: 03/05/2024

NARRATIVE

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Per review of records and interviews, there are times R1 is out of the community with POA and/or other family member(s), and may miss their supplement shake being provided to them, this is documented in records. Required parties are notified of R1's missed medication order, per record reviews. There is differing information obtained in the investigation regarding the allegation that "staff are not following Physicians orders". There was no information obtained that supported that a violation had occurred.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "staff are not following Physicians orders" 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 Maria Cortes.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC9099 (FAS) - (06/04)

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