Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 09/06/2018
Date Signed: 09/06/2018 11:31:16 AM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/16/2017 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-SC-20171016155019
FACILITY NAME:VILLA CAPRIFACILITY NUMBER:
496802026
ADMINISTRATOR:SMITH, DEBORAHFACILITY TYPE:
740
ADDRESS:1397 FOUNTAINGROVE PARKWAYTELEPHONE:
(707) 526-9090
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:80CENSUS: DATE:
09/06/2018
UNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Debbie Smith-AdministratorTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Facility staff failed to evacuate residents during a fire.


INVESTIGATION FINDINGS:
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Licensing Program Analyst Alviso, and Licensing Program Manger Martinez, delivered findings, on 9/6/18, of the complaint allegation above; LPA and LPM met with Debbie Smith and Nathan Condie, Administrators'. Oakmont’s Villa Capri is licensed for a capacity of 80. According to information received from the Vice President of Quality Assurance and Regulatory Affairs, Staff 15 (S15), on the night of October 8, 2017, and the morning of October 9, 2017, there were 62 residents in care with four staff on shift that night; Staff 5 (S5), S7, S8, and S9. Villa Capri is a Residential Care For Elderly facility who serves residents over the age of 60, some of whom may present with dementia as well as nonambulatory. Non-amb, a person who is unable to leave a building unassisted under emergency conditions. It includes, but is not limited to, those persons who depend upon mechanical aids such as crutches, walkers, and wheelchairs. It also includes persons who are unable, or likely to be unable, to respond physically or mentally to an oral instruction relating to fire danger and, unassisted, take appropriate action relating to such danger.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2018
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 13
Control Number 21-SC-20171016155019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026
VISIT DATE: 09/06/2018
NARRATIVE
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On October 8 and 9, 2017, the Santa Rosa area sustained widespread wildfires, forcing evacuations of multiple residential care facilities. On October 26, 2017, the Department initiated a complaint investigation into an allegation that facility staff failed to evacuate residents during the wildfire and left the facility while some residents were still inside the facility.

The Department conducted on-site visits, interviewed 10 staff, 10 residents, first responders, City officials, family members, and other witnesses. The Department reviewed the Santa Rosa Police Department (SRPD) police reports, SRPD body camera footage, resident records, the facility’s Plan of Operation, and the facility’s Disaster Planning policies, and procedures dated February 16, 2017.

Per correspondence the Department received on November 10, 2017 from the Vice President of Quality Assurance and Regulatory Affairs, all 25 of the residents in the memory care portion of the building are considered non-ambulatory, since they cannot exit unassisted in the event of an emergency. The “memory care section” is the residential area of the building that houses residents with a diagnosis of dementia. According to the facility’s floor plan, the second floor houses 37 assisted living residents. Of the 37 residents in assisted living, there were 22 residents who were non-ambulatory per S15. Based on interviews, the power went on and off during the night of the fire and therefore, residents who required assistance evacuating, or were non-ambulatory, had to evacuate via the stairs instead of the elevator. Interviews conducted by the Department and review of records indicated that four staff (S5, S7, S8, and S9) were present during the night shift, but were unsure of the facility’s Emergency Evacuation Procedures. Although staff assisted with some portions of the evacuations, they did not ensure that all residents were evacuated.

The Department conducted a review of the Villa Capri file, which contained the Oakmont “Disaster and Emergency Manual for Assisted Living and Residential Care Communities.” During an interview, S15 indicated via correspondence on October 16, 2017, that the Disaster and Emergency Manual contained their evacuation procedures.

Continued on LIC9099C...
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2018
LIC9099 (FAS) - (06/04)
Page: 2 of 13
Control Number 21-SC-20171016155019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026
VISIT DATE: 09/06/2018
NARRATIVE
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The manual, on page 82, explains that the Primary Emergency Assembly Point (EAP) is to “coordinate a head count of all residents, staff, and visitors using the Resident Roster, Visitor Sign-In/Out Sheet, and Employee Sign-In/Out Sheet,” and “If it is safe to do so, the appropriate Safety Supervisors conduct a sweep of their areas of the building to locate any individuals not accounted for during the head count.” Based on the staff interviews, these steps were not taken by S5, S7, S8 and S9.

SRPD indicated in their reports that upon their arrival at the facility at approximately 3:45 a.m. on October 9, 2017, there were an estimated 20 residents in the building who required assistance evacuating. Some of the 20 residents were hearing impaired, in a wheelchair, or needed transfer assistance. Further, Emergency Responders stated that upon their arrival, there were no staff present to assist in locating and evacuating other residents in the building.

Staff interviews revealed that staff S5, S7, S8 and S9 did not have adequate training in emergency disaster procedures. S7, who is the designated substitute in absence of the Administrator, stated they did not have an evacuation plan to follow. When S7 was hired they were told what to do if the fire was inside the building, but did not know anything about what to do if they needed to evacuate due to an emergency outside the building. S8 stated that she wasted an hour trying to locate the bus keys and no staff on duty had access to the bus keys. S8 stated that she was not trained in emergency procedures or an evacuation plan. S5 also stated that she, and the other staff on duty, did not know where the keys to the busses were. Staff S5 and S7 evacuated on Oakmont buses driven by a maintenance worker (S2) from a sister facility and a family member of a resident, who came to assist residents being evacuated. S8 was interviewed and stated that a resident’s family member advised S8 that, due to the proximity of the fire to the building, there was no time left and instructed the two remaining staff (S8 and S9) to bring their personal cars up to the front of the building so they could load residents into the cars. S8 left with three residents and, shortly thereafter, S9 followed with three additional residents.

Continued on LIC9099C...
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2018
LIC9099 (FAS) - (06/04)
Page: 4 of 13
Control Number 21-SC-20171016155019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026
VISIT DATE: 09/06/2018
NARRATIVE
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S9 was interviewed and stated that she was the last staff to leave when she evacuated in her own vehicle with three residents, there were two family members remaining at Villa Capri with approximately 20 residents still needing to be evacuated. Per interviews conducted with family members and the SRPD police reports, Emergency Responders did not arrive until after all staff had evacuated with a portion of the residents. The remaining residents were evacuated with the assistance of family members and Emergency Responders.

The Department interviewed staff, S1, who was not at the facility the night of the fires, who stated that since they started working at Villa Capri (beginning February 2016), they had not conducted a disaster drill where all residents and staff evacuated the building.

Based on SRPD reports, records review, interviews with family members, residents, and staff on duty the night of the fires, and information obtained during the investigation the allegation regarding “facility staff failed to evacuate residents during a fire” is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

California Code of Regulations, (Title 22, Division 6, Chapter 8) and/or Health & Safety Code, is being cited on the attached LIC 9099Ds.

Licensee was notified case was referred to legal, appeal procedures will accompany the legal pleading.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2018
LIC9099 (FAS) - (06/04)
Page: 3 of 13
Control Number 21-SC-20171016155019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2018
Section Cited
HSC
1569.695(a)(1)
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Emergency Plans 1569.695(a)(1) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency plan that shall include, but not be limited to, all of the following:(1) Evacuation procedures. This requirement was not met as evidenced by: based on interviews & record reviews, the licensee failed to ensure the facility’s
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Refer to Legal For Administrative Action
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emergency plan, including evacuation procedures which is documented in the facility program, was implemented on the night of October 8, 2017, and the morning of October 9, 2017 during a mandatory evacuation due to a wild fire. This posed an immediate health & safety risk to the residents in care.
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Type A
09/06/2018
Section Cited
HSC
1569.269(a)(6)
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Enumerated Rights: 1569.269(a)(6) Residents of residential care facilities for the elderly shall have all of the following rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This
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requirement was not met as evidenced by: based on interviews and record review, the licensee failed to ensure enough staff were available the night of fires to safely evacuate all residents, which posed an immediate health & safety risk to the residents 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.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2018
LIC9099 (FAS) - (06/04)
Page: 5 of 13
Control Number 21-SC-20171016155019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2018
Section Cited
HSC
1569.625(c)(6)
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Staff Training 1569.625(c)(6) Training shall include…building and fire safety and the appropriate response to emergencies; This requirement was not met as evidenced by: Based on interviews & record review the licensee failed to ensure 4 of 4 staff (S5, S7, S8 and S9)
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were appropriately trained in building & fire safety and the appropriate response to emergencies. This posed an immediate risk to the health and safety of the residents in care.
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Type A
09/06/2018
Section Cited
CCR
87212(b)(A-F)
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Emergency Disaster Plan 87212(b)(A-F) Supervision of residents during evacuation or relocation and contact after relocation to assure that relocation has been completed as planned. This requirement was not met as evidenced by: based on interviews and record review the licensee failed to ensure
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4 of 4 staff (S5, S7, S8 and S9) on duty the night of October 8, 2017, and the morning of October 9, 2017, assisted all residents during the evacuation relocations, and did not ensure that approximately 20 resident relocations were completed. This posed an immediate risk to the health and safety of the residents 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.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2018
LIC9099 (FAS) - (06/04)
Page: 6 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/16/2017 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-SC-20171016155019

FACILITY NAME:VILLA CAPRIFACILITY NUMBER:
496802026
ADMINISTRATOR:SMITH, DEBORAHFACILITY TYPE:
740
ADDRESS:1397 FOUNTAINGROVE PARKWAYTELEPHONE:
(707) 526-9090
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:80CENSUS: DATE:
09/06/2018
UNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Debbie Smith- AdministratorTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Staff failed to inform family of evacuation.



INVESTIGATION FINDINGS:
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Licensing Program Analyst Alviso, and Licensing Program Manger Martinez, delivered findings, on 9/6/18, of the complaint allegation above; LPA and LPM met with Debbie Smith and Nathan Condie, Administrators'. On October 26, 2017, the Department initiated a complaint investigation into the allegation that staff failed to inform family of evacuation. The Department interviewed staff and family members regarding the evacuations that took place due to the wild fires in Santa Rosa on the night of October 8, 2017, and the morning of October 9, 2017.

This allegation is related to the evacuation of a resident referred to as R1 in this report. R1 was evacuated from Villa Capri in the early morning hours of October 9, 2017, due to fires in the area. R1 was taken to the New Vintage Church evacuation shelter where facility staff were onsite to care for the residents evacuated from Villa Capri. An interview with S4 indicated that R1 fell while at the evacuation shelter, and was transported to a local hospital by Emergency Medical Technicians (EMT).
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2018
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 13
Control Number 21-SC-20171016155019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026
VISIT DATE: 09/06/2018
NARRATIVE
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When S4 flagged down EMTs at the evacuation shelter to transport R1 to the local emergency room, S4 did not have any resident records to send with the EMTs. Records were not removed from the facility when staff evacuated. In addition, S4 did not have the contact numbers at the evacuation shelter to alert R1’s family that she was being transported to a local area hospital. Per family, R1 was admitted to the hospital as a “Jane Doe,” and due to the fires in the area had to be evacuated a second time from that hospital to another hospital about 20 minutes away. Interviews with family stated that they could not find R1 for several hours after R1 left the evacuation shelter. This information was corroborated by other family members who reported not being noticed for hours after learning that Villa Capri was evacuated. Families where not noticed what evacuation sites the residents were taken to. R11 and R12’s daughter was not noticed for over 8 hours of the whereabouts of her parents. R11 and R12 were located at a local evacuation shelter, which had to be re-evacuated to a secondary location. No notice was given to families of where they were going, no signs on the door. R11 and R12 were found over two hours away, after family members began calling Assisted Living communities outside of the area.

Based on the interviews, record review, and information obtained during the investigation the allegation regarding “staff failed inform family of evacuation” is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

California Code of Regulations, (Title 22, Division 6, Chapter 8) and/or Health & Safety Code, is being cited on the attached LIC 9099Ds.

Licensee was notified case was referred to legal, appeal procedures will accompany the legal pleading.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2018
LIC9099 (FAS) - (06/04)
Page: 10 of 13
Control Number 21-SC-20171016155019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2018
Section Cited
CCR
87468(a)(8)
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Personal Rights 87468(a)(8) .Each resident shall have the right to have family members or responsible persons regularly informed of activities related to his/her care or services. This requirement is not met as evidenced by: Based on interviews, the licensee failed to ensure that residents R1, R11, and R12's
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Refer to Legal For Administrative Action
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responsible party(s) was notified of resident's whereabouts in a timely manner during evacuations on October 9, 2017. This posed an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2018
LIC9099 (FAS) - (06/04)
Page: 9 of 13
Control Number 21-SC-20171016155019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2018
Section Cited
CCR
87468(a)(8)
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Personal Rights 87468(a)(8) Each resident shall have the right to have family members or responsible persons regularly informed of activities related to his/her care or services. This requirement is not met as evidenced by: Based on interviews, the licensee failed
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to ensure records with contact information were removed from the facility during the evacuation, preventing staff from informing responsible persons of activities related to care or services. This posed an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2018
LIC9099 (FAS) - (06/04)
Page: 11 of 13
Control Number 21-SC-20171016155019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2018
Section Cited
CCR
87405(d)(1-5)
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Administrator Qualifications & Duties 87405(d)(1-5) When the administrator is not in the facility, there shall be coverage by a designated substitute who shall be qualified to be responsible for administration of the facility. This requirement was not met as evidenced by: based on interviews & record review, licensee failed to ensure that designated substitute (S7) who was on site the night of October 8,2017, & morning of October 9, 2017, gave clear directions necessary for the evacuation of the residents, communicated with emergency responders, or provided
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Refer to Legal For Administrative Action
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leadership to staff to implement facility's written & established emergency plan as identified in facility program. S7 was not able to access master keys & keys to transportation vehicles. This failure delayed evacuation of approximately 20 of 63 residents. S7 was one of the first staff to evacuate with a bus load of residents, leaving two untrained staff & residents behind. This posed an immediate risk to health & safety of residents in care.
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Type A
09/06/2018
Section Cited
CCR
87415(a)
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Night Supervision 87415(a) The following persons providing night supervision from 10 p.m. to 6 a.m. shall be familiar with the facility's planned emergency procedures. This requirement was not met as evidenced by: based on interviews the licensee failed
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Refer to Legal For Administrative Action
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to ensure 4 of 4 staff on the night shift were familiar with the facility’s emergency procedures. This posed an immediate health & safety risk to the residents 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.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2018
LIC9099 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/16/2017 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-SC-20171016155019

FACILITY NAME:VILLA CAPRIFACILITY NUMBER:
496802026
ADMINISTRATOR:SMITH, DEBORAHFACILITY TYPE:
740
ADDRESS:1397 FOUNTAINGROVE PARKWAYTELEPHONE:
(707) 526-9090
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:80CENSUS: DATE:
09/06/2018
UNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Debbie Smith- AdministratorTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Staff neglect resulted in resident sustaining serious injury.

INVESTIGATION FINDINGS:
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Licensing Program Analyst Alviso, and Licensing Program Manger Martinez, delivered findings, on 9/6/18, of the complaint allegation above; LPA and LPM met with Debbie Smith and Nathan Condie, Administrators'. The Department conducted a complaint investigation into the allegation that staff neglect resulted in a resident sustaining serious injury. The Department interviewed staff regarding the evacuations that took place due to the wild fires in Santa Rosa on the night of October 8, 2017, and the morning of October 9, 2017, and reviewed resident records.

This allegation is related to the evacuation of a resident referred to as R1 in this report. R1 was evacuated from Villa Capri in the early morning hours of October 9, 2017, due to fires in the area. R1 was taken to an evacuation shelter where facility staff were onsite to care for the residents evacuated from Villa Capri.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2018
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-SC-20171016155019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026
VISIT DATE: 09/06/2018
NARRATIVE
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Per interviews with a Registered Nurse from Villa Capri (referred to as S4), S4 went to the shelter to assist residents. While at the shelter, S4 heard a noise and heard R1 say “ow”. S4 said they approached R1 who appeared to have slipped off a chair to the floor. R1 was complaining of pain and indicated it was in the hip area. S4 sought assistance from Emergency Medical Technicians (EMTs) who had just parked their vehicle at the shelter. According to S4, the EMTs assessed R1 and suspected a possible injury to R1’s hip. Based on medical records and interviews, the resident suffered a broken hip, which required surgery. Although the staff did not have resident records, S4 was able to provide personal information to the EMTs, who then transported R1 to a local area hospital.

Based on the interviews, record review, and information obtained during the investigation the allegation that “staff neglect resulted in resident sustaining serious injury” is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2018
LIC9099 (FAS) - (06/04)
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