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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 07/23/2025
Date Signed: 07/23/2025 03:31:13 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 Ali Deniz
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:
07/23/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Camille BrownTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility did not follow infection control plan
INVESTIGATION FINDINGS:
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At approximately 11:45AM, 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. The following allegation was investigated, “Facility did not follow infection control plan.” The complaint alleged that there is an outbreak of scabies and multiple residents are infected. Interview conducted with Executive Director indicated that the facility had 3 suspected cases of scabies in May 2025. Review of incident report submitted to Community Care Licensing on 05/29/2025 showed that per their infection control protocols, facility contacted their Local Public Health to inform them of the suspected cases.

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

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
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: 07/23/2025
NARRATIVE
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Continued from LIC9099

Incident report also stated that facility increased their cleaning protocols and provided training to facility staff on the topic of Hand Hygiene, Infection Control, and Standard Precautions on 05/27/2025. Per Executive Director, the houses were being cleaned twice per week. Review of Housekeeping schedule indicated that homes were cleaned twice per week with alternating schedules. Based on record review and interviews conducted, 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: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3