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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802026
Report Date: 10/14/2022
Date Signed: 10/14/2022 04:32:45 PM


Document Has Been Signed on 10/14/2022 04:32 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:LIMBERG, STEPHANIEFACILITY TYPE:
740
ADDRESS:1397 FOUNTAINGROVE PKWYTELEPHONE:
(707) 526-9090
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:80CENSUS: 59DATE:
10/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Stephanie Limberg-AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Prigram Analyst (LPA) Alviso conducted a case management inspection, and met with Administrator Stephanie Limberg.

The case management is being conducted to review several resident incident reports. The LPA reviewed the incident reports with the Administrator; LPA obtained more information on resident incidents and reviewed records of the incident(s).

In review of two incident reports regarding medication errors, the following citation will be issued, 87465(a)(4) Incidental Medical and Dental Care, see LIC809D.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited, see LIC809D.

Exit interview conducted with the Administrator Stephanie Limberg.
Appeal Rights Given.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/14/2022 04:32 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/15/2022
Section Cited
CCR
87465(a)(4)

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(a) 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: (4) The licensee shall assist residents with self-administered medications as needed.
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POC CLEARED BY ADMINISTRATOR PROVIDING INSERVICE ON MEDICATION ASSITANCE TO STAFF THAT GAVE MEDICATION IN ERROR PER REPORTED INCIDENTS (2).
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LPA reviewed two incident reports of staff not providing correct medication dosage and/or correct medication for the resident which resulted in two incidents of medication errors. This is a health and safety risk and/or personal rights violation to the residents in care.
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 Licensee to ensure that all residents are provided medication assistance by qualified staff and that medications are being provided per Physician's Orders. Administrator provided copies of training(s).

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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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