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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804010
Report Date: 12/05/2024
Date Signed: 12/05/2024 04:13:42 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
09/09/2024 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20240909112350
FACILITY NAME:VINCENT, THEFACILITY NUMBER:
216804010
ADMINISTRATOR:CORRINE BIANCOFACILITY TYPE:
740
ADDRESS:1 LAS GALINAS AVETELEPHONE:
(628) 336-1400
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:126CENSUS: 64DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Administrator/Executive Director, Corrine Bianco, and Memory Care Direcotor, Sammy HoweidyTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Facility mismanaged medications
Facility staff not administering medications per physician orders
INVESTIGATION FINDINGS:
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At approximately 9:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Executive Director/Administrator, Corrine Bianco, and Memory Care Direcotor, Sammy Howeidy.

During the Investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Facility mismanaged medications, and Facility staff not administering medications per physician orders.” Complainant alleged that facility staff were not administering medication timely and were falsifying medication administration documentation.

The Regional Office received six (6) self-submitted incident reports from the facility. These reports stated that for five (5) residents, medication was not administered timely or was missed completely. Review of the 6th incident report stated that a resident was administered someone else’s medication.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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-20240909112350
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: VINCENT, THE
FACILITY NUMBER: 216804010
VISIT DATE: 12/05/2024
NARRATIVE
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Continued from LIC9099

3 of 7 interviews conducted with involved parties stated that residents have been observed to receive their medication late, sometimes over two hours, or that residents have been given the wrong medication intended for other residents. (deficiency cited and civil penalty issued, LIC9099D and LIC421IM, regulation 87465(a)(4)).

LPA is unable to determine if medication records were falsified, however based on incident reports reviewed and interviews conducted, the allegations are Substantiated.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

**An Immediate Civil Penalty in the total amount of $1,000.00 is being assessed for a third violation of Regulation 87465(a)(4) more than once in a 12 month period. Deficiencies last cited on 02/08/2024 and 07/24/2024. (See LIC421IM)**

Exit interview conducted. Copy of report, LIC421IM (Civil Penalty), LIC811 (Confidential Names), and Appeal Rights, discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240909112350
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: VINCENT, THE
FACILITY NUMBER: 216804010
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care(a)...each facility...shall provide for assistance...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review and interviews, Licensee did not comply with
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Licensee to submit self-certification that In-service training will be conducted by POC due date of 07/25/2024. Training to be done for all staff that administer medications reviewing when to order medications per facility protocol. Inservice Training to include the following information: Date of Training,
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the section cited above. 6 Incident Reports received and 3 of 7 interviews conducted stated that residents have either missed medication, received late medications, or have been given someone else's medication. This poses an immediate health and safety risk to residents in care.
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Training Topics, Job Role, Staff Names and Signatures. Training to be submitted by POC due date of 08/05/2024.
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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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3