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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 12/17/2024
Date Signed: 12/17/2024 04:48:02 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
12/12/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241212113741
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: DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Cortes-AdministratorTIME COMPLETED:
05:00 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 12/17/24 at approximately 10:00am, and met with Administrator Maria Cortez. LPA also met with Memory Care Director Gao Yang, and Health & Wellness Director Jennifer Haney.

LPA reviewed resident (R1) records, including medication orders/medications. The LPA requested copies of resident (R1) records, and facility records. Administration staff provided the requested copies to the LPA. The LPA conducted interviews with staff (S1, S2, S3), and other related parties. The investigation revealed that R1's medications are filled by the responsible party (RP) of R1, and brought into the facility to be centrally stored for R1. Per review of records and interviews, there was no documentation and/or date of when R1's medications were provided by the RP to the facility. The facility medication staff didn't document how many bottles of R1's eye medications were provided by RP, there are three (3) different type of eye drops prescribed; No documentation of how many containers of the prescribed powder mix medication was delivered by RP.

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

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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-20241212113741
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: 12/17/2024
NARRATIVE
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It is unknown by review of information/record reviews/interviews that eye drop medications were not provided to R1 as prescribed.

Facility policy states that medication refills are to be ordered seven days prior to running out. R1's care plan states that RP is to be notified when medications need to be filled, minimum of two weeks in advance notice to RP. Staff were not able to provide proof of a two week in advance request to RP to order R1's powder mix medication. R1 missed the AM dose and will miss the PM dose due to the medication ran out, and is just now on order, R1 will continue to miss the dose till the order is received by RP.


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.

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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20241212113741
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: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2024
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care-A plan for incidental medical and dental care shall be developed by each facility. 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
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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, ensuring the two week notice is sent out to the RP of R1, and maintaining necessary records to ensure compliance with regulations. Maintain all medication records accurately and keep them up to date.
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to running out. R1's care plan states that RP is to be notified when medications need to be filled, minimum of two weeks in advance. R1's last dose of their powdered mix medication was 12/16/24, and today, 12/17, R1 missed the AM dose and will miss the pm dose due to the medication is out, and is just now on order, waiting to be filled, per interviews with staff and other related parties. This is a risk to residents health & safety and personal rights.
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Hold an in-service training with all medication staff regarding refills/orders in a timely manner, and record keeping. Submit plan regarding medications as stated above and discussion of facility's future compliance. POC due 12/18/24.
*Submit proof of training by 12/23/24.
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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: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
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