<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 01/29/2026
Date Signed: 01/29/2026 02:00:59 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
12/03/2025 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20251203140207
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: 42DATE:
01/29/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director, Camille BrownTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not follow resident's special diet
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 09:30 AM, Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Executive Director, Camille Brown.

During the course of the investigation, the Department conducted interviews, reviewed records, and made observations. The following allegation was investigated: “Facility did not follow resident’s special diet.”

The complaint alleged that Resident 1 (R1) experienced an allergic reaction after consuming food at the facility. The Reporting Party (RP) stated that on 11/18/2025, the facility notified them that R1’s lips were swollen. The RP transported R1 to the hospital, where a doctor reportedly stated R1 had an allergic reaction to something ingested. The RP stated that a staff member mentioned apple pie was served and believed cinnamon may have caused the reaction, as R1 is allergic to cinnamon.
Continued on LIC9099-C page...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
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
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
12/03/2025 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20251203140207

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: 42DATE:
01/29/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director, Camille BrownTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not ensure drinking containers were clean and sanitary
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 09:30 AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Executive Director, Camille Brown.

During the course of the investigation, the Department conducted interviews, reviewed documents, and made observations. The following allegation was investigated: “Facility did not ensure drinking containers were clean and sanitary.”

The complaint alleged that on 11/18/2025, when the Reporting Party (RP) arrived at the facility to transport R1 to the hospital, they asked a caregiver to fill R1’s water bottle with ice water. While at the hospital, the RP observed a black unknown substance floating inside the water bottle and expressed concern that staff were not properly cleaning residents’ drinking containers.
Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20251203140207
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: 01/29/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099-A page...

LPA interviewed the RP, who reported a visible unknown black substance around the edges of a water bottle. LPA reviewed the evidence and confirmed the presence of the unknown substance. The RP stated that they were confident the bottle had not been properly sanitized by staff. Based on the evidence provided by the RP and interviews conducted, the preponderance of evidence supports that the facility failed to ensure that R1’s drinking container was clean and sanitary.

Based on interviews and evidence reviewed, this allegation is Substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs). Failure to correct the cited deficiencies by the Plan of Correction (POC) due date may result in civil penalties.

Exit interview conducted. A copy of the report, LIC 9099D (Deficiency Page), Plan of Correction, and Appeal Rights were discussed and provided to the Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20251203140207
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: 01/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2026
Section Cited
CCR
87555(b)(29)
1
2
3
4
5
6
7
87555(b)(29) - General Food Service Requirements, (b)The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agrees to provide in-service training to all direct care staff on proper cleaning and sanitizing of resident drinking containers and implement a routine cleaning schedule to ensure all containers remain clean and sanitary.
8
9
10
11
12
13
14
Based on interviews and LPA observation of records, it was determined that resident R1’s water bottle contained unknown black substance, that indicating it was not properly cleaned or sanitized. This poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Administrator will submit proof of correction by Plan of Correction(POC )due date 02/10/2026.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20251203140207
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: 01/29/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099 page...

LPA reviewed the facility menu for the date in question and found no food items listed that contained cinnamon. LPA also reviewed the facility’s diet and allergy boards, which documented R1’s allergy information. Interviews with facility staff did not confirm that cinnamon-containing foods were prepared or served to R1. During a follow-up interview, the RP stated they did not have evidence to support the allegation and acknowledged R1 was assuming. The RP further stated that R1 has dementia and may not recall events clearly.

Based on interviews and record review, there was insufficient evidence to support that the facility failed to follow R1’s special diet. Therefore, this allegation is UNSUBSTANTIATED. An unsubstantiated finding means there is not enough evidence to prove or disprove the allegation.

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: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5