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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804010
Report Date: 12/12/2025
Date Signed: 12/12/2025 01:26:19 PM

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
07/23/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20250723122303
FACILITY NAME:VINCENT, THEFACILITY NUMBER:
216804010
ADMINISTRATOR:PARI,MANOUCHEHRIFACILITY TYPE:
740
ADDRESS:1 LAS GALINAS AVETELEPHONE:
(916) 472-8363
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:126CENSUS: 83DATE:
12/12/2025
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Executive Director/Administrator, Pari ManouchehriTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff did not properly address resident's falls resulting in an injury
INVESTIGATION FINDINGS:
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At approximately 8:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Administrator, Pari Manouchehri.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegation, “Staff did not properly address resident's falls resulting in an injury.” Complaint alleged that Resident 1 (R1) was admitted to the hospital post-fall and sustained bruising and a large hematoma. Complaint stated this was the second fall R1 had in the past few months at the facility.

Interview with Executive Director stated that R1 had a history of aggression, agitation, and being combative. R1 returned to the facility on 07/31/2025 with a private caregiver. Per Executive Director, facility had a care

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

DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
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 3
Control Number 21-AS-20250723122303
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: 12/12/2025
NARRATIVE
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Continued from LIC9099

conference with R1’s responsible party in May 2025 to discuss R1’s behaviors and alternative options but was unable to provide any written documentation of the meeting.

Interview with Memory Care Director stated that the facility and R1’s responsible party decided to have a private companion for R1 at nighttime. Memory Care Director further explained during R1’s most recent fall in July 2025, R1 did not have their private companion anymore since it had been decided by R1’s responsible party that it was no longer needed.

Correspondence with R1’s Responsible Party (RP) stated that R1 had private caregivers for a few months and slowly reduced their hours over time. Per RP, R1 had private caregivers from 04/27/2025 to 06/09/2025. RP stated that R1 had 24/7 care from 04/27/2025 - 05/13/2025, and reduced hours from 05/14/2025 to 06/09/2025. RP further stated that after R1’s fall in July 2025 it was decided that R1 would go back to have 24/7 private caregivers and begin receiving hospice services.

Review of R1’s documentation showed the following:


· Incident report submitted to Community Care Licensing (CCL) on 04/24/2025 stated that on 04/19/2025, R1 had gotten stuck with their walker between a recliner chair and the living room couch and was unable to maneuver back out. Report stated that facility staff were trying to help R1 but R1 became resistive. R1 picked up their walker and swung it at facility staff and fell on their right side hitting their head on the couch. Staff were unable to catch R1. Report stated that R1 was admitted to the hospital for evaluation where it was found that they had sustained a right pelvis fracture and contusion to the right side of their head.
· Facility Progress Notes indicated that R1 had a fall on 06/05/2025 with no physical injuries notated. R1 attempted to sit in a chair that was too far away and ended up sitting on the floor. Notes stated that R1’s primary care physician and responsible party were contacted.
· Incident report submitted to CCL on 07/29/2025 stated that on 07/18/2025, R1 had an unwitnessed fall during night shift. Report stated that R1 was sleeping on the facility’s living room couch. Facility staff stepped away for approximately 5 minutes and when they returned, R1 was observed face down on the floor. Report states that R1 sustained a bump to their head and was sent to the hospital for further evaluation.
· R1 returned to the facility on 07/31/2025 with hospice services.

Continued on LIC9099C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250723122303
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: 12/12/2025
NARRATIVE
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Continued from LIC9099C

Facility did not have a care plan available to review after R1’s fall in April 2025. Review of R1’s care plan dated 07/31/2025, stated that R1 had disruptive and aggressive behaviors and that a behavior management plan may be put in place. Per care plan, R1 was at a high risk for falls due to unsteady gait. Facility staff were to frequently check on R1, ensure they were visible while in the common spaces of the facility, and ensure their walker was within reach at all times. R1’s care plan dated 09/29/2025, stated that most of R1’s behaviors were refusals of care or occurred due to other residents and being overstimulated. Staff were to assess R1’s mood and agitation level or implement techniques such as changing of face or redirection. This care plan also stated that R1 required stand-by assistance with transferring and reminders to use their walking device. Facility staff were to frequently check R1, make sure they were visible in the common areas, and ensure their walker was within reach at all times when R1’s private caregiver was not present.

Review of progress notes stated that on 08/29/2025, the facility held a care conference with R1’s responsible party to address R1’s care. Additional items such as having designated care staff work with R1, R1 having a higher assessment level than expected, and facility providing weekly updates were also discussed. Review of progress notes and Resident Charge form indicated that facility reached out to R1’s responsible party to discuss updated changes to R1’s September 2025 care plan on 09/07/2025, 09/16/2025, and 09/29/2025 but did not receive a response.

Based on record review, interviews conducted, and observations made, Department is unable to determine if a violation of Title 22 Regulations occurred, therefore this 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 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: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3