496802026-4-28-2023-21-AS-HDBI-CSMR22-20230609123737

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 04/28/2023
Date Signed: 04/28/2023 05:42:59 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/24/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230124085904

FACILITY NAME:	VILLA CAPRI		FACILITY NUMBER:	496802026
ADMINISTRATOR:	LIMBERG, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	1397 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 526-9090
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	80	CENSUS: 62	DATE:	04/28/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Eugenia Smith-Interim Administrator		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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Facility staff did not appropriately assist resident with toileting
Facility staff handled resident roughly
Facility staff are not following physicians orders to bathe resident
Facility staff speak inappropriately to residents
Facility staff are not meeting resident's dietary needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 4/28/23 at approximately 9:40am, LPA met with Administrator Eugenia Smith.

LPA reviewed five (5) resident files, and three(3) staff files. All resident files had required records, including care plans, medication records, and medical documentation. Staff files reviewed had required records. LPA interviewed staff, and other related interested parties regarding the allegations.

The investigation revealed that three(3) of three(3) staff have required trainings for caregivers that provide services to residents. Staff work in both assisted living, and in the dementia care unit.

Continued on LIC9099...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230124085904

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/28/2023

NARRATIVE

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In review of records, and interviews with all staff, and other parties, residents receive bathing/showering as needed and required, including if ordered by the Physician.Residents have a shower list of when they have showers during the week. If a resident refuses staff will ask again, and if refused again by the resident, staff will report to their Supervisor so they can follow-up on providing the shower to the resident. Residents are not handled roughly and/or spoken to inappropriately by staff providing any care needs/services to resident(s), per interviews. Per record reviews and interviews, residents are receiving toileting/incontinent needs as required; Staff are trained to meet the toileting needs and care services provided to residents in care. Per interviews, toileting needs are being met by staff for residents in care. Residents dietary needs are being met by the facility staff per interviews and record reviews. The facility has a record log of all dietary needs for residents on special diets. The Kitchen staff is made aware and provides special diet meals and snacks for residents requiring it. If a resident is eating a food they shouldn't a resident in memory care would be redirected as needed, other food items/snacks will be offered, per interviews. LPA obtained copies of Special Diet records from the binder. There was no information obtained that supported a substantiation that violations occurred regarding the allegations.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations, Facility staff did not appropriately assist resident with toileting, Facility staff handled resident roughly, Facility staff are not following physicians orders to bathe resident, Facility staff speak inappropriately to residents, Facility staff are not meeting resident's dietary needs are, Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies cited during todays visit.
Exit interviews were conducted.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

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