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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 03:33:26 PM

Substantiated


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
05/30/2025 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20250530124825
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:
12:11 PM
MET WITH:Administrator, Camille BrownTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff do not maintain facility in safe, sanitary and good repair
INVESTIGATION FINDINGS:
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At approximately 11:40AM/PM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations 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, “Staff do not maintain facility in safe, sanitary and good repair.” Complainant alleged that “facility staff do not clean the bathrooms, that there is poop on the bathroom floors and that facility staff wipe the tables with the same towels used to wipe the chairs which is unsanitary.” The Department found that these concerns listed by the Complainant were not a violation of Title 22 regulations. During visits conducted on 05/06/2025, 06/04/2025, and 06/19/2025, LPAs observed that facility bathrooms were clean and did not have feces on the floor.

Continued on LIC9099...
Substantiated
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-20250530124825
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...

However, LPAs also observed the following items to be in disrepair:
• Paper towel dispenser was removed from the bathroom wall
• Toilet paper holder was broken
• Facility shower bathroom had a “out of order” sign for the toilet
• Soap dispensers was broken
• Utility sink in facility laundry room was clogged

Based on these observations, the allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

*During visit on 07/23/2025, LPAs observed that all items identified to be in disrepair were fixed. Deficiency cited today has been cleared.

Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, Plan of Corrections Letter and Appeal Rights discussed and provided to Executive Director/Administrator. 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
Control Number 21-AS-20250530124825
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times...for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on observations made, Licensee did not comply with the section cited
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During visit on 07/23/2025, LPAs observed that facility has fixed all items that were in disrepair. Deficiency Cleared.
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above and did not ensure that bathrooms were in good operating condition. LPAs observed the following to be broken or in disrepair: paper towel dispenser, toilet paper holder, toilet out of order, soap dispenser, and utility sink. This poses a potential health and safety risk to residents 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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

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

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