486803645-1-14-2026-21-AS-VBEI-DQJNQ7-20260121093929

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 01/14/2026
Date Signed: 01/14/2026 01:38:03 PM

Unfounded

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
01/07/2026 and conducted by Evaluator Ali Deniz

COMPLAINT CONTROL NUMBER: 21-AS-20260107110256

FACILITY NAME:	VACAVILLE MEMORY CARE		FACILITY NUMBER:	486803645
ADMINISTRATOR:	CAMILLE BROWN		FACILITY TYPE:	740
ADDRESS:	431 NUT TREE ROAD		TELEPHONE:	(707) 449-1350
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	75	CENSUS: 41	DATE:	01/14/2026
		UNANNOUNCED	TIME BEGAN:	01:21 PM
MET WITH:	Administrator, Camille Browm		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff not following care plan when assisting resident with ADLs.
Staff violated residents personal rights.

INVESTIGATION FINDINGS:

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At approximately 09:35 AM, on 01/14/2026, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to continue a complaint investigation and deliver findings regarding the above allegations. LPA met with the facility Administrator, Camille Brown.
During the course of the investigation, the Department conducted interviews, reviewed records, and made observations. The following allegations were investigated, "Staff did not follow care plan when assisting a resident with Activities of Daily Living (ADLs) and staff violated a resident’s personal rights."

The complaint alleged that during the PM shift, a staff member attempted to transfer a resident using a Hoyer lift without the requuested two-person assist, resulting in a staff injury and raising concerns regarding the resident’s safety.
LPA interviewed the Administrator and facility staff, who stated that no residents require the use of a Hoyer lift and that while some residents require a two-person assist, none require Hoyer lift transfers. Staff denied knowledge of any incident or staff injury involving a Hoyer lift.
Contiued on LIC9099-C...

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20260107110256

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: 01/14/2026

NARRATIVE

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Continued from LIC9099...

Facility representatives stated that no staff member by the name referenced in the complaint is employed at the facility and that the facility does not use three-digit room numbers; no resident was identified as occupying the room number referenced.
LPA reviewed facility records, including resident care plans and incident reports. Record review did not identify any resident documented as requiring a Hoyer lift, nor did records reflect any reported incident or injury related to Hoyer lift usage on or around 01/05/2026.

Based on record review, interviews conducted, and observations made, there was insufficient evidence to support the allegations that staff failed to follow a resident’s care plan when assisting with ADLs or that staff violated a resident’s personal rights.

Therefore, the allegation is UNFOUNDED means that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview was conducted and a copy of this report was signed and given to the Administrator.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

LIC9099 (FAS) - (06/04)

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