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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 07/11/2025
Date Signed: 07/11/2025 04:09:07 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
05/01/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20250501124124
FACILITY NAME:VACAVILLE MEMORY CAREFACILITY NUMBER:
486803645
ADMINISTRATOR:CAMILLE BROWNFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 60DATE:
07/11/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Camille BrownTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Facility did not provide sufficient staffing to intervene when a resident physically assaulted another resident
INVESTIGATION FINDINGS:
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At approximately 1:00PM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Administrator, Camille Brown.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation of “Facility did not provide sufficient staffing to intervene when a resident physically assaulted another resident.” Complaint alleges that Resident 1 (R1) was physically assaulted by Resident 2 (R2) resulting in R1 receiving bruises on their head, neck, chest, and their right eye being “swollen shut.” Pictures and video of the bruises were provided showing bruising as described by the complainant. Per complainant, R2 has exhibited this behavior towards other residents, however, interview with Executive Director, Camille Brown indicated that resident had been observed grabbing other residents but had not exhibited behavior this severe. Review of Special Incident Reports do

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

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
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-20250501124124
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: VACAVILLE MEMORY CARE
FACILITY NUMBER: 486803645
VISIT DATE: 07/11/2025
NARRATIVE
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Continued from LIC9099

not show any other incidents involving R2 with other residents. Per interview with staff involved, R2 walked into R1’s room three to four times but staff was able to be verbally redirect R2. The fourth time, while staff was in the room, R2 punched R1 in the eye and then left. Staff did not observe R2 hit R1 in any other part of their body. Staff requested assistance by the Medication Technician and R1 was assessed approximately an hour later by a hospice nurse and was treated for their eye. Per interview with the Executive Director, R2 has had medication changes and increased supervision due to their behaviors since this incident. Witnesses have reported seeing R2 the facility without staff, however, LPAs observed R2 with supervision during visits on 5/6/2025, 6/4/2025, and 07/11/2025.

Based on document review, interviews conducted, and observations made, 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: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3