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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802026
Report Date: 10/01/2024
Date Signed: 10/01/2024 02:39:11 PM


Document Has Been Signed on 10/01/2024 02:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:VILLA CAPRIFACILITY NUMBER:
496802026
ADMINISTRATOR:CORTES, MARIAFACILITY TYPE:
740
ADDRESS:1397 FOUNTAINGROVE PKWYTELEPHONE:
(707) 526-9090
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:80CENSUS: 64DATE:
10/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Maria Cortes (Executive Director)TIME COMPLETED:
02:54 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Other Visit, and met with Executive Director, Maria Cortes. The purpose of this Case Management Visit is to follow up on a SOC341 report dated 7/23/24 along with an incident report notifying Community Care Licensing (CCL) about a suspected physical abuse incident that happened on 7/17/24 at 3am.

Per incident report, on 7/22/24 at approximately 2:30pm, staff (S2) reported to the Executive Director about an incident that occurred on 7/17/24 around 3am resident (R1) was in another resident's apartment. S2 was attempting to redirect them back to their apartment, but R1 was exhibiting aggressive behaviors. At that time, S2 called for assistance from another staff (S1), while S1 was trying to redirect them R1 walked towards S1 by speaking out loud and S1 pushed R1 that R1 almost fell. Upon reported to Executive Director, the facility contacted law enforcement on 7/22/24. The police report incident #SR-242050248 and case number #24-8824. On 7/23/24 at 10am, the facility staff performed a skin assessment of R1 with no injuries found. Responsible parties were notified. Per facility policy, S1 was suspended pending further investigation. On 7/24/24, in-service training to the staff was conducted regarding elder abuse/mandated reporter.

During today's visit, the facility provided LPA, S1's resignation letter dated 7/25/24 indicating that they are resigning due to them feeling disappointed with the facility regarding this incident by sending law enforcement to their residence. Based on records review, the facility conducted an internal investigation, where the findings including resignation letter received was a concern for the facility. However, internal investigation results were unsubstantiated. LPA reviewed staff (S1 & S2) training records including the in-service conducted on 7/24/24 with other staff excluding S1, who was suspended at that time.

The facility provided staff contact information to LPA. The Department will review information obtained to determine if further action is needed.

No deficiencies cited during today's inspection. Exit interview was conducted with Executive Director and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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