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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 07/02/2026
Date Signed: 07/02/2026 03:10:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/16/2026 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20260416084717
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: DATE:
07/02/2026
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Brooke Patterson, AdministratorTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff did not follow the doctor's orders for resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings on the above allegation. LPA met with Administrator Brooke Patterson.

Complaint alleges staff did not follow the doctor's orders for resident in care. Complainant states that resident was prescribed fentanyl patches for end-of-life comfort care but facility denied resident use of patches. During investigation, LPA conducted interview with facility’s corporate RN nurse, Kari Miller (RN) who reported that as of February 2026, she developed a “RCFE Hospice Coordination Checklist for Administrators,” which states in bold font that fentanyl patches are not allowed for pain management. Per interview with RN, the facility has not provided any disclosure to prospective residents or current residents indicating the no fentanyl patches policy and does not currently have a written policy disclosing to residents the denial of fentanyl patches used for comfort care.

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026
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 3
Control Number 21-AS-20260416084717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/02/2026
NARRATIVE
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Continued from 9099...

During investigation, LPA conducted interviews. Three (3) out of three (3) witnesses report that R1 was denied use of fentanyl patches by RN. Per interview, after prolonged discussion with R1’s physician, RN eventually approved the use of the patches for R1. Fentanyl patches were prescribed to R1 for comfort care on 3/19/26 at 11:36am and according to Villa Capri Observations notes were administered at 10:03pm. Additionally, three (3) out of three (3) witnesses report subsequent resident (R2) was prescribed comfort care fentanyl patches and was also denied the use of the patches. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20260416084717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2026
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility… (2) The licensee shall provide assistance in meeting necessary medical and dental needs.

This requirement is not met as evidenced by:
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Facility to submit written policy indicating how the facility will meet the requirements of following physicians' medication orders to meet the necessary medical needs of residents.
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Based on LPA interview and record review, the licensee did not comply with the section cited above in that facility refused to adminsiter R1's physician prescribed medication which poses an immediate health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3