216804010-5-22-2025-21-AS-VBEI-DH3TEP-20250527144012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804010
Report Date: 05/22/2025
Date Signed: 05/22/2025 11:00:35 AM

Unsubstantiated

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
12/04/2024 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20241204092912

FACILITY NAME:	VINCENT, THE		FACILITY NUMBER:	216804010
ADMINISTRATOR:	CORRINE BIANCO		FACILITY TYPE:	740
ADDRESS:	1 LAS GALINAS AVE		TELEPHONE:	(628) 336-1400
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	126	CENSUS: 86	DATE:	05/22/2025
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Executive Director/Administator, Pari Manouchehri		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Unexplained injury

INVESTIGATION FINDINGS:

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At approximately 9:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegations and met with Executive Director, Pari Manouchehri.

During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Unexplained Injury.” Complainant alleged that Resident 1 (R1) sustained a fracture and questioned if the facility had handled the incident appropriately. Report received on 12/04/2024 stated that R1’s Responsible Party was notified by both the facility and R1’s hospice team on the same day,10/29/2024, for observed swelling to R1’s shoulder. Review of facility documents showed that R1 was receiving hospice care. Review of Hospice notes showed that hospice agency staff conducted routine visits with R1 for their Activities of Daily Living (ADLs) and did not observe
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

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-AS-20241204092912

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: 05/22/2025

NARRATIVE

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Continued from LIC9099

any changes in condition during the following visits: 10/21/2024,10/24/2024,10/25/2024, and 10/28/2024. Additional notes dated for 10/29/2024 – 10/31/2024 indicated that R1 had an x-ray completed. X-ray results found that R1 sustained a shoulder fracture and would require a sling. The Department was unable to find additional documentation or evidence to identify how R1’s injury occurred or if there were other changes in condition prior to it being observed by facility staff and the hospice agency staff on 10/29/2024. Based on documents reviewed and observations made, the allegation is Unsubstantiated.

A finding that a 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 and LIC811 (Confidential Names) 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: 05/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

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