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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804010
Report Date: 04/21/2025
Date Signed: 04/21/2025 02:14:58 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
12/17/2024 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20241217093631
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: 78DATE:
04/21/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director, Pari Manouchehri, Journey Director, Sammy Howeidy, and Regional Health and Wellness Director, Rochelle Factor, and Vice President of Clinical Operations, Mariam PerezTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not assist with self-administration of medications as needed
Staff falsely recorded medication as being dispensed to resident
INVESTIGATION FINDINGS:
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During the Office Meeting, Licensing Program Manager (LPM) Bertozzi and Licensing Program Analyst (LPA) Felias delivered findings for this Complaint Investigation regarding the above allegations and met with Executive Director, Pari Manouchehri, Journey Director, Sammy Howeidy, Regional Health and Wellness Director, Rochelle Factor, and Vice President of Clinical Operations, Mariam Perez.

During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff did not assist with self-administration of medications as needed and Staff falsely recorded medication as being dispensed to resident.” Complainant alleged that Resident 1 (R1) had not been receiving their routine eye drop or inhaler medications and Facility Staff were falsifying resident medication records by documenting that R1’s medication was given even if the medication was not available. Complainant also alleged that facility staff are leaving medication with R1 and not ensuring that they are being taken.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
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 5
Control Number 21-AS-20241217093631
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: 04/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2025
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
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Licensee to submit self-certification that a written plan and supporting documents will be submitted to CCL by POC due date of 05/01/2025. Plan to include a hybrid model consisting of competency checks, shadowing, and additional training.
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with the section cited above and R1 was being administered expired medications. Interviews conducted also stated that medications were being left unattended in resident rooms after being dispensed. This poses an immediate health and safety risk to residents in care.
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Type B
05/02/2025
Section Cited
CCR
87208(a)
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87208 Plan of Operation(a)The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation... pursuant to Health and Safety Code…This requirement was not as
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Licensee to submit self-certification that a written plan and supporting documents will be submitted to CCL by POC due date of 05/01/2025. Plan to include a hybrid model consisting of competency checks, shadowing, and additional training.
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evidenced by: Based on interviews conducted, Licensee did not comply with the section cited above. Medication records were being documented as given when medication was not readily available. This poses an potential 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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/17/2024 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20241217093631

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: DATE:
04/21/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director, Pari Manouchehri, Journey Director, Sammy Howeidy, and Regional Health and Wellness Director, Rochelle Factor, and Vice President of Clinical Operations, Mariam PerezTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility did not follow resident’s care needs
INVESTIGATION FINDINGS:
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During the Office Meeting, Licensing Program Manager (LPM) Bertozzi and Licensing Program Analyst (LPA) Felias delivered findings for this Complaint Investigation regarding the above allegation and met with Executive Director, Pari Manouchehri, Journey Director, Sammy Howeidy, Regional Health and Wellness Director, Rochelle Factor, and Vice President of Clinical Operations, Mariam Perez.

During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Facility did not follow resident’s care needs.” Complainant alleged that R1’s hearing aids were getting lost, facility staff did not know how to put them in correctly, and that the hearing aid batteries weren’t being charged. Complainant also stated that because the hearing aids are not properly placed, R1would pull the hearing aids out.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20241217093631
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: 04/21/2025
NARRATIVE
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Continued from LIC9099

LPA conducted interviews with witnesses and facility staff. Interviews conducted provided conflicting information. Interview conducted with W1 stated that facility staff would either forget to put R1’s hearing aids on in the morning or forget to take them off at night, resulting in R1’s hearing aids getting lost and needing replacement. W1 also stated that facility staff did not receive training on how to insert R1’s hearing aids and that the hearing aids were rechargeable and did not use batteries.

Interview conducted with Memory Care Director stated that facility staff were taught how to insert R1’s hearing aids by R1’s family as the insertion is different compared to other hearing aid models. Interview also stated that R1’s hearing aids are to be inserted by the facility medication technicians, and they receive a notification from facility staff when R1’s hearing aid filters have been changed.

Interview conducted with facility staff stated that they received training on how to insert R1’s hearing aids, that R1’s hearing aids are rechargeable, and that R1’s hearing aid filters are changed weekly. Per interview conducted, R1’s hearing aids are charged in the medication room and only medication technicians are to insert them. Review of facility documents indicated that facility staff were documenting when R1’s hearing aid filters were changed and when R1 would refuse to have their hearing aids put in.

Based on interviews conducted and record review, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.

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

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20241217093631
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: 04/21/2025
NARRATIVE
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Continued from LIC9099

Review of R1’s physician orders from 08/08/2024 showed the following instructions for R1’s routine inhaler and eyedrops:

· Alvesco 160MCG Inhaler (60); Inhale 2 puffs by mouth daily for asthma prevention and control, rinse mouth well after use


· Dorzolamide HCL 2% Eye Drops; Instill 1 drop in both eyes twice daily for glaucoma
· Latanoprost 0.005% Eye Drops; Instill 1 drop in both eyes every evening

LPA conducted interviews with witnesses and facility staff. 3 of 4 interviews stated that they had heard of medication being documented as given or administered when the medication was unavailable or not in the cart. Interview conducted with facility staff stated that they have seen medication in resident rooms that have not been given.

Review of Facility documentation showed that a medication training was conducted by the Health and Wellness Director in February 2025. Additional documentation showed that another training was conducted by the Regional Health and Wellness Director on the topics of medication refills, proper documentation, and medication administration in March 2025.

Email correspondence and photographs provided to the LPA revealed that a medication audit was conducted on 02/21/2025 where it was found that R1’s medications were not given as prescribed. Interviews conducted with Regional Health and Wellness Director and Memory Care Director confirmed that a medication audit for R1 took place where medication errors were found such as administering expired medications. Based on interviews conducted, record review, and observations made, these 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 deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

**A Civil Penalty in the total amount of $250.00 is being assessed for a repeat violation of Regulation 87465(a)(4) more than once in a 12 month period. Deficiency last cited on 12/05/2024. (See LIC421FC)**

Exit interview conducted. Copy of report, LIC421FC (Civil Penalty), Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents.

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

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5