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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 03/30/2026
Date Signed: 03/30/2026 01:05:16 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
01/28/2026 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20260128150922
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: 43DATE:
03/30/2026
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Executive Director, Camille BrownTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Staff physically abused resident.
INVESTIGATION FINDINGS:
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At approximately 12:25 PM, 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: “Staff physically abused resident.”
The complaint alleged that on 01/27/2026, a staff member physically assaulted a resident by tackling R1 from behind and punching the resident after refused to follow a directive.

On 01/28/2026, the facility self-reported the incident by submitting an SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) to Community Care Licensing (CCL). According to the report, staff member S1 and resident R1 were involved in a physical altercation. Another staff member attempted to de-escalate the situation.
Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
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 3
Control Number 21-AS-20260128150922
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: 03/30/2026
NARRATIVE
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Continued from LIC9099 page...

Management instructed S1 to leave the facility and contacted 911. S1 was terminated on the same day as the incident.

Based on interviews conducted, records reviewed, and information obtained, it was determined that staff member S1 used physical force against resident R1, including tackling and striking the resident. Such actions constitute physical abuse. The facility failed to ensure that residents are free from physical abuse and failed to protect the resident from staff misconduct.

Based on interviews conducted, records reviewed, and observations made, the facility failed to ensure compliance with Title 22 regulations regarding resident rights and protection from abuse; therefore, 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. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20260128150922
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: 03/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2026
Section Cited
CCR
87468.1(a)(3)
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87468.1(a)(3) Personal Rights of Residents in All Facilities: (a)(3) To be free from punishment,humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’...
This requirement was not met as evidenced by:
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Executive Director agrees to provide all staff training regarding abuse, de-escalation and crisis training. ED will submit proof of correction by Plan of Correction (POC )due date 04/10/2026.
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Based on interviews conducted, records reviewed, and observations made, the facility failed to ensure resident’s rights and protection from abuse. This poses a potential health, safety or personal rights risk to persons 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: 03/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
LIC9099 (FAS) - (06/04)
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