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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803077
Report Date: 02/16/2022
Date Signed: 02/16/2022 12:27:39 PM

Substantiated


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
02/01/2022 and conducted by Evaluator Katrina Walters
COMPLAINT CONTROL NUMBER: 21-AS-20220201133243
FACILITY NAME:VICTORPAZ FARMHOUSEFACILITY NUMBER:
486803077
ADMINISTRATOR:GOMEZ, ANNALEEFACILITY TYPE:
740
ADDRESS:506 KINGS WAYTELEPHONE:
(707) 439-3757
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:6CENSUS: 6DATE:
02/16/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Annalee GomezTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Resident's rates were raised without proper notice.
Admission's Agreement is not being adhered to.
INVESTIGATION FINDINGS:
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On 2/16/22 Licensing Program Analyst (LPA) Walters arrived unannounced to deliver findings for the above complaint allegations that Licensee, did not adhere to the admission agreement and that Licensee did not give proper notice for rate increase. LPA was greeted by staff, the Administrator, Annalee Gomez arrived later.

The department received this complaint on 02/01/2022. On 02/02/2022, LPA conducted a facility visit to tour the facility and gather information. During the course of this investigation, LPA gathered resident R1’s Admission Agreement, Physician’s Report (LIC 602), Power of Attorney, Needs and Service Appraisal, Staff charting notes, hospice records, and interviewed staff.


Continued on 9099 C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
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-20220201133243
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: VICTORPAZ FARMHOUSE
FACILITY NUMBER: 486803077
VISIT DATE: 02/16/2022
NARRATIVE
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The investigation revealed that during a resident care meeting, Licensee, Melissa Gomez issued a verbal 30 day notice rate increase notification to the responsible party of R1, however R1’s admission agreement revealed that the facility is to issue rate increases in writing and give 60 days’ notice, unless there is an increase in the level of care that results in a rate increase. The notice must itemize the charges. R1’s records did not indicate a change of condition. Based on the information obtained during the course of the investigation through interviews, and record review a preponderance was established to SUBSTANTIATE this complaint. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and Health and Safety Code (cited on 9099-D). Appeal rights given to the Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20220201133243
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: VICTORPAZ FARMHOUSE
FACILITY NUMBER: 486803077
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2022
Section Cited
HSC
1569.655(a)
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1569.655(a) If a licensee.. increases the rates of fees for residents the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident.
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Administrator to send LPA Walters a copy of the rate incerase in writing prior to issuing rate increase to residents. Administrator to submit copy by POC due date (2/21/22), attention LPA Walters.
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Based on record review, the licensee did not comply with the section cited above in one of six residents which poses/posed a potential health, safety or personal rights risk to persons 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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3