<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802026
Report Date: 04/28/2023
Date Signed: 04/28/2023 05:36:29 PM

Unfounded


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
04/20/2023 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230420164901
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: 62DATE:
04/28/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Eugenia Smith-Interim AdministratorTIME COMPLETED:
05:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have an acting administrator in charge
Facility is in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 4/28/23 at approximately 9:40am, LPA met with Oakmont's Interim Administrator Eugenia Smith.

LPA requested documentation on the current Administrator coverage and received copies from Interim Administrator; LPA requested documentation on the elevator incident, and all documentation on how this incident was addressed. LPA interviewed staff S1, regarding the Administrator coverage of Villa Capri, and the elevator incident and repair(s). Investigation revealed that Villa Capri has had an Interim Administrator Eugenia Smith. Eugenia Smith is a Regional Operations Specialists of Oakmont Management Group LLC, and has worked 4/17/23 through to today, 4/28/23. The Administrator works Monday through Friday 9am to 6pm, and there are lead staff on-site on the weekends. If there is an emergency and/or if the Administrator is needed the lead staff can reach out to the Administrator. Typically, the Administrator is off on the weekends. The lead staff will have the Administrator's phone and email contact if needed in the event of an emergency and/or if a resident or responsible party has an immediate need that only the Administrator can handle with them.
Continued on LIC9099C...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (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)
Page: 1 of 2
Control Number 21-AS-20230420164901
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
There was no information obtained during this investigation to support a violation had occurred regarding Administrator coverage in the facility.

LPA interviewed staff S1, regarding the elevator incident, and repair(s). LPA requested copies of documents, and received them from the Administrator during the visit. Investigation revealed that the elevator went out of service at approximately 7:55am on 4/14/23, and the Elevator Technician was called out to inspect and repair the elevator. The Technician identified that a circuit board had malfunctioned and needed to be replaced. This part had to be ordered, and the Technician would return once the part was received. The Technician explained to the Administration staff that in an emergency such as 911 and/or resident Dr. Appointment(s) or to get residents dependent on wheelchairs back up to their rooms on the 14th, they could use the outside elevator buttons to call up the elevator and/or to call the elevator down. The circuit board(s) that went out control the buttons inside of the elevator. The facility also has emergency disaster plans, and evacuation plans if needed in an emergency.

The facility ensured all meals would be delivered, activities would also be held on the second floor for residents wanting to participate. A few residents were assisted to use the elevator for their Doctor appointments, and it was used to move a few residents back to the second floor on the 14th. All residents were notified on the 14th by staff, including information provided on plan to provide all needed services while the elevator was down. Responsible parties of residents were also notified on the 14th. The Technician came into the facility and worked on the elevator 4/18 but the elevator still needed an additional circuit board. The part was received and the Technician repaired the elevator, and it was available for resident use late afternoon. on 4/21/23. Resident services returned back to normal operation. Licensing was also notified as required regarding the incident, facility's plan of action, and repairs completed. There was no information obtained during this investigation to support a violation had occurred regarding the facility was in disrepair. The incident was addressed appropriately per regulations.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations, Facility does not have an acting administrator in charge
Facility is in disrepair, are Unfounded. We have found that the complaint allegations was Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
No deficiencies cited during todays visit.
Exit interviews were conducted.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (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)
Page: 2 of 2