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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802026
Report Date: 03/18/2025
Date Signed: 03/18/2025 06:33:30 PM

Document Has Been Signed on 03/18/2025 06:33 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VILLA CAPRIFACILITY NUMBER:
496802026
ADMINISTRATOR/
DIRECTOR:		CORTES, MARIAFACILITY TYPE:
740
ADDRESS:1397 FOUNTAINGROVE PKWYTELEPHONE:
(707) 526-9090
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 80TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
03/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:55 PM
MET WITH:Maria Cortes-AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:33 PM
NARRATIVE
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Licensing Prigram Analyst (LPA) Alviso conducted a case management inspection, on 3/18/25 at approximately 3:55pm, and met with Administrator Maria Cortes. LPA met with Gao Yang, Journey Director.

The case management is being conducted to review a resident incident that the facility Administrator reported to the Department. LPA reviewed records on the resident (R1) and on staff (S4, S5). LPA obtained additional information on the resident incident, and obtained copies of documentation/records. Required reports were completed, submitted to all required parties.
Per interviews and documentation provided by the administration staff, Administrator and Journey Director, stated training has been provided to staff regarding mandating reporter, and training in providing care to the residents; Proof of the training was provided to the LPA.

Per review of records, interviews with staff, S1 and S2, and interviews with other related parties, it was identified that staff (S4, S5) inappropriately handled (R1) when trying to provide incontinent care to them, and R1 was refusing care from the staff. (R1) reacted by screaming and kicking at staff when they handled R1 inappropriately. Staff didn't use a different approach and/or stepping away and allowing some time to the resident to be agreeable to the incontinent care needed.

The following deficiency will be cited regarding the reported resident (R1) incident and information obtained during today's inspection,
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, see LIC809D.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.



Exit interview conducted with the Administrator Maria Cortes.
Appeal Rights Provided to the Administrator.
Bethany MoellersTELEPHONE: (707) 588-5040
Dina AlvisoTELEPHONE: (707) 588-5082
DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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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Document Has Been Signed on 03/18/2025 06:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2025
Section Cited
CCR
87468.2(a)(4)

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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. This requirement was not met as evidenced by:
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Licensee/Administrator to ensure all caregiving staff in memory care/journey care unit have "Resident Rightd/Personal Rights" training, ensure both staff, S4 & S5 are included. Submit proof of training, include attendees, date/time spent, topics covered, and qualified trainer's name/title. POC due 3/31/25.
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Per review of records, interviews with staff, S1 and S2, and interviews with other related parties, it was identified that staff (S4, S5) inappropriately handled (R1) when trying to provide incontinent care to them, and R1 was refusing care from the staff. (R1) reacted by screaming and kicking at staff when they handled R1 inappropriately. Staff didn't use a different approach and/or stepping away and allowing some time to the resident to be agreeable to the incontinent care needed. This is a risk to residents personal rights.
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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.
Bethany MoellersTELEPHONE: (707) 588-5040
Dina AlvisoTELEPHONE: (707) 588-5082

DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025

LIC809 (FAS) - (06/04)
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