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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 09/12/2025
Date Signed: 09/12/2025 01:37:08 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
05/01/2025 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: 50DATE:
09/12/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH: Administrator, Camille BrownTIME COMPLETED:
01:59 PM
ALLEGATION(S):
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Facility did not meet resident's incontinence care needs
Facility does not have sufficient staff to provide care and supervision to residents
INVESTIGATION FINDINGS:
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At approximately 09:40AM, Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings for 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, “Facility did not meet resident's incontinence care needs.” Facility does not have sufficient staff to provide care and supervision to residents.”
“Facility did not meet resident’s incontinence care needs” – Complaint alleged that night staff leave residents “soaked” in their incontinence briefs. Complainant also stated that R1 was observed to have a puddle of urine underneath them and wasn’t changed by Staff Member 1 (S1) when R1 was taken to the bathroom. Complainant stated that the incident was witnessed by Staff Member 2 (S2). LPAs spoke with S1who recalled the incident.

Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
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 5
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: 09/12/2025
NARRATIVE
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Continued from LIC9099...

Per S1, they changed R1’s depends in the bathroom but put R1’s pants back on because they couldn’t find any clean clothes in R1’s closet. LPAs spoke with S2, who was unable to recall details of the incident.
Based on interview conducted, this 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.

Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, 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: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a)In addition to the rights listed in Section 87468.1,... shall have all of the following personal rights: (4) to care, supervision, and...This requirement was not met as evidenced by:
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Licensee to schedule training with approved outside vendor for all care staff regarding personal rights of residents and incontinence care . Licensee to provide scheduled training date to CCL by POC due date of 09/15/2025. Training to include:
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Based on interviews conducted and observations made, Licensee did not ensure residents' personal rights and incontinence care needs were met. This is an immediate health and safety risk to residents in care.
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Staff Names and Signatures. Training to be submitted by POC due date of 09/25/2025.
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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: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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: 50DATE:
09/12/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH: Administrator, Camille BrownTIME COMPLETED:
01:59 PM
ALLEGATION(S):
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Facility does not have sufficient staff to provide care and supervision to residents
INVESTIGATION FINDINGS:
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At approximately 09:40AM, Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings for 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, “Facility does not have sufficient staff to provide care and supervision to residents.”

“Facility does not have sufficient staff to provide care and supervision to residents.” Complaint alleged that when a staff member is assisting another resident, the other resident has to wait for a period of time to be assisted. Complainant was unable to provide a length of time on how long a resident has to wait for care to be provided. Interview with Executive Director and staff interviews conducted stated that there are usually 2 staff members in each house as well as two medication technicians available each shift. 2 of 13 staff interviews stated they had concerns about staffing while other interviews conducted stated...

Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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: 09/12/2025
NARRATIVE
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Continued from LIC9099-A...

they had seen improvement in staffing and felt that there was enough staffing available to meet residents’ needs. Review of facility documents indicated that as of June 2025, the facility had 12 residents requiring 2-person assistance for care needs such as transferring. Review of facility schedules indicated that the facility had at least 2 staff members in each house to meet the needs of residents. During visit conducted on 08/14/2025, LPAs observed that each house had two caregivers assigned.

Based record 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: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5