496802026-1-28-2025-21-AS-BMOS-DGNUL3-20250514154003

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 01/28/2025
Date Signed: 01/28/2025 03:56:57 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
01/27/2025 and conducted by Evaluator Dina Alviso

COMPLAINT CONTROL NUMBER: 21-AS-20250127143918

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:	DATE:	01/28/2025
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Maria Cortes-Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Medications are not provided to the resident as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 1/28/24 at approximately 10:15am, and met with Administrator Maria Cortes. LPA also met with Memory Care Director Gao Yang. Health & Wellness Director Jennifer Haney was unavailable to meet with the LPA during the inspection.

Reporting party alleges that "medications are not provided to the resident as prescribed". LPA reviewed resident (R1) records, including medication orders/medications records. The LPA obtained copies of records requested. The LPA conducted interviews with staff (S1, S2), and other related parties. The investigation revealed that R1's medications, two (2) medications, one routine order and one PRN order, were identified as not having been provided to the resident as ordered by the Physician. The routine medication order, medication order #1, is to be provided to the resident twice daily, an am dose and a pm dose. R1's routine medication ran out on 1/18/25, and the refill hadn't been requested by staff to be ordered until the medication ran out. R1 missed a total of eight (8) doses of the medication, a pm dose on 1/18, two doses on 1/19, 1/20/ and on 1/21, and an am dose on 1/22. The medication was delivered to the facility on 1/22/25, and the resident, R1,was provided a pm dose of the medication.
Continued on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

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-20250127143918

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: 01/28/2025

NARRATIVE

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Continued from LIC9099...

R1's PRN medication, medication order #2, is to be provided as needed at "bedtime".This medication was prescribed for psychosis, agitation, and anxiety as needed at bedtime on 12/6/2023, per Doctor's Order. On 10/1/24, the Doctor prescribed the medication order as needed in the evening for psychosis, agitation, and anxiety only. In review of PRN records, "PRN Given Report", the medication has been provided outside of "bedtime" hours, listed were some of the following hours observed, 9:51am, 1:13am, 2:03am, and 12:42am. LPA also observed that some of the entries listed this medication being provided to R1 for sleep and insomnia, which it is not prescribed for, per Doctor's Order.

Facility policy states that medication refills are to be ordered seven days prior to running out. R1's care plan states that Representative is to be notified when medications need to be filled, minimum of two weeks advance notice to R1's Representative. This was not done regarding medication order #1.

There is sufficient information obtained to support that a violation has occurred regarding the reported allegation of "medications are not provided to the resident as prescribed". This deficiency will be cited, 87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed, see LIC9099D. Civil Penalty assessed at $250 for repeat violation within 12 months, see LIC421FC.

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 the Administrator Maria Cortes.
Appeal Rights Provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20250127143918

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: 01/28/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/28/2025 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) Incidental Medical and Dental Care- The licensee shall assist residents with self-administered medications as needed. This requirement was not as evidenced by: LPAs record reviews, interviews, and observations, Facility policy states that medication refills are to be ordered seven days prior to running out. R1's care plan states that R1's Representative is to be notified a, minimum of two weeks in advance for refills.	1 2 3 4 5 6 7	Licensee/Administrator to ensure all residents receive their medications as prescribed by the Physician. Submit a plan on how the facility will ensure that R1's medications are ordered/filled in a timely manner, and that PRN medications are provided to the resident per dosage instructions on Doctor's Orders, including time frame given, and reason for giving the medication.
	8 9 10 11 12 13 14	R1 missed 8 doses of Medication Order #1, and has been provided medication order #2 outside of dosage hours, and given for sleep/insomnia which is not per the Dr's Order. This is a risk to residents rights & health&safety. Civil Penalty assessed at $250 for repeat violation within 12 months, LIC421FC.	8 9 10 11 12 13 14	Hold an in-service training with all medication staff regarding refills/orders in a timely manner, record keeping, and Dr's instruction Orders on PRNs. Submit plan regarding medications as stated above and on plan regarding facility's future compliance. POC due 1/28/25. *Submit proof of training by 2/7/25.
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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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC9099 (FAS) - (06/04)

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