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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 09/03/2025
Date Signed: 09/03/2025 05:29:10 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
08/29/2025 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250829102706
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: 67DATE:
09/03/2025
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Gao Yang- Memory Care Director.TIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Facility staff did not appropriately address resident's change in condition, and seek medical attention in a timely manner

Required partiy (s) not notified timely of resident's change in condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/3/2025 at approximately 9:50am, and met with Gao Yang, Memory Care Director.

RP alleges that "facility staff did not appropriately address resident's change in condition and seek medical attention in a timely manner, and required partiy (s) not notified timely of resident's change in condition".
LPA requested resident (R1) records, including care plan, medical assessment, medications, progress notes, and all communication documents regarding resident's change in condition, including notification to required parties, Physician, and responsible party, LPA obtained copies of requested records. LPA interviewed staff/S1, Kaiser Physician, Home Health Nurse, and other related parties, regarding allegations. Per LPA record reviews, and interviews conducted, the investigation revealed that R1 was observed to have a change in condition, more confusion and not at thier baseline, on 8/18/25. The staff faxed a notification to R1's medical physician's office, of R1's change in condition, on 8/18/25.

Continued on LIC9099C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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-20250829102706
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: 09/03/2025
NARRATIVE
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Per interviews and medical records, a Dr's Order was placed for R1 to obtain lab work, to see if there was anything that could be causing the resident's change in condition. Facility staff, S1, stated they don't have and/or never received a Dr's Order for R1 to obtain lab work. S1 stated that there was a never a response from the Physician/medical office on the faxed notification on 8/18/25.
Staff S1 was not able to provide any follow-up to the resident R1's Physician regarding the 8/18/25 notification of change in condition, from 8/18/25 through to 8/24/25,10:20am. Per record review, there was a fax document regarding R1's change in condition dated 8/24/25, faxed at 10:20am to resident R1's Physician. R1 continued to be declined with confusion from their baseline as known, per review of records. Before 8/24/25 at 10:20am, there was no follow-up contact made by the facility to the Physician regarding R1's change in condition of 8/18/25.
Per file reviews and interviews, Home Health Nurse (HHN) contacted Physician's office and notified them of R1's change in condition, and crackles in lungs, on 8/26/25. Per record reviews, HHN was told by staff on 8/25/25 when seeing R1, that R1 was more confused than their baseline. Per record reviews, there was no documentation of resident's responsible party (RP) being notified of resident R1's change in condition back on 8/18/25 or the next day, on 4/19/25; There was a mention of responsible party being aware when resident R1 was sent out 911 due to Physician's request, on 8/28/25. Per interviews and obtained documentation, reporting party was notified on 8/28/25 the need of R1 to be seen for lab work related to change of condition since 8/18/25, R1 needed to be evaluated by a medical professional regarding change in condition, including Home Health Nurse hearing crackles in resident's lungs. Per interviews, RP and reviewed obtained documentation, RP was notified by the facility on 8/27/25 that resident had a change of condition; Rp had no notification/information regarding 8/18/25, when Physician was faxed about change in R1's condition.

There was sufficient information obtained to support violations had occurred regarding the allegations, "facility staff did not appropriately address resident's change in condition and seek medical attention in a timely manner, and required partiy (s) not notified timely of resident's change in condition". Deficiency will be cited, 87466 Observation of the Resident, 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.

Exit interview conducted with Gao Yang, Memory Care Director.
Appeal Rights Provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250829102706
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: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2025
Section Cited
CCR
87466
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87466 Observation of the Resident, The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Licensee to ensure all observed changes in residents are followed-up on when notifying resident's Physician, until the resident changes have been addressed. Ensure responsible parties are notified as required by regulation when changes are observed. Hold an in-service training with your staff regarding this requirement by regulation, "Observation of the Resident"
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This requirement was not met as evidenced by: LPA's investigation, R1 was observed to have a change in condition, on 8/18/25, Physician was faxed about R1's changes observed, but there was no follow-up after this date till 8/24/25 at 10:20am, per record reviews. RP was not notified per file reviews, obtained information, and interviews, until 8/27/25 that resident had a change of condition. This is a personal rights risk to resident in care.
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Ensure staff understand the policy of observations of the resident, including documenting what has been done on notifications, what is being done, any changes in monitoring of the resident/care plan updates, and any follow-up needed. Submit proof of training and facility's future compliance by 9/15/25.
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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: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3