486804297-12-30-2025-21-AS-SSTN-DPUSEN-20251230124900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804297
Report Date: 12/30/2025
Date Signed: 12/30/2025 12:49:10 PM

Document Has Been Signed on 12/30/2025 12:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	VACAVILLE SENIOR ASSISTED LIVING, LLC		FACILITY NUMBER:	486804297
ADMINISTRATOR/ DIRECTOR:	SAMANIEGO, AGUSTIN		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(323) 902-6000
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY: 160		CENSUS: 78	DATE:	12/30/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Executive Director Agustin Samaniego		TIME VISIT/ INSPECTION COMPLETED:	12:55 PM

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	At approximately 9:40 AM Licensing Program Analyst (LPA) arrived to conduct a change of ownership (CHOW) pre-licensing inspection with residents in care and met with Executive Director Agustin Samaniego. Facility is a one story building currently licensed for 95 non-ambulatory and 5 bedridden residents, along with a hospice waiver capacity of 10 and hospice exceptions granted for 2. The facility currently provides care for 78 residents, 10 of which are receiving hospice services, as well as two (2) bedridden residents. New owners have received a fire clearance for 160 non-ambulatory residents, 30 of which can be bedridden. In addition, the facility has applied for a hospice waiver increase from 10 to 11. Facility will continue to have a delayed egress memory care unit. LPA was given copy of facility building and grounds map with legend including, “Unit Occupancy Potential”. Parking is noted to be in the front and left side of the building. At approximately 10:15 AM LPA continued with a tour of the facility with the Executive Director. Facility has an updated Emergency and Disaster Plan for Residential Care Facilities LIC610E and Infection Control Plan on file that will need to be updated with new phone numbers and emails addresses reflected in the new ownership once new license is issued. Facility currently has a Theft Policy posted that will need to be updated with the new facility name. A “Rights of Resident Councils” poster is prominently placed at the facility accessible to residents, family members, and resident representatives. Emergency Personnel poster is a public/central location, as well as, Personal Rights, Non-Discrimination and Complaint making process posters. Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025

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

LIC809 (FAS) - (06/04)

Page: 1 of 4

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 SENIOR ASSISTED LIVING, LLC	FACILITY NUMBER: 486804297
	VISIT DATE: 12/30/2025

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 LIC809
There was at least 2 days of perishable and 7 days non-perishable foods as required by Title 22 Regulations with food delivered twice a week. Licensee is advised of the need to have increased food supplies on hand as census expands. Food stored in the kitchen was properly stored as per regulations. Facility currently monitors resident diets with appropriate dietary restrictions posted on kitchen bulletin board with a discreet photograph of each resident that requires a special diet/consistency.

Toxins are stored in designated facility storage closets located throughout the facility.

Facility has traditionally invited local school children to interact with residents. Residents are visited by families that routinely interact with one another in the dining area, common spaces as well as in resident private apartments. The facility provides an eclectic range of activities specified for both assisted living and memory care engagement. Facility is noted to have large common areas indoors and outdoors, a grand piano, holiday decorations, hair salon, library, as well as, a television/theater experience in the memory care unit.

Facility has a transport van with 1st aid kit and a pare key is stored in the business office with other important keys.

All exits have functional auditory alarms. Facility has awake staff at night to respond to residents’ individual signal system on neck pendants, as well as pull cords at the heads of beds and along bathroom toilets.

Fire Extinguishers found throughout the facility were found to be fully charged and last inspected on 02/2025. Facility has 34 fire extinguishers. Both smoke detectors and sprinkler/alarm systems throughout the facility were interconnected, and inspected by an outside agency with current certification dated 06/10/2025 with no deficiencies cited. Additional carbon monoxide detectors located in both assisted living and memory care sections of the facility were also found to be in working order. Windows, doors, walls, ceilings, screens, paint, and furniture are in good condition.
Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 SENIOR ASSISTED LIVING, LLC	FACILITY NUMBER: 486804297
	VISIT DATE: 12/30/2025

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 LIC809C

Medications were found centrally stored and secure in both assisted living and memory care as required by regulation and medicine administration was found to be accurately documented.

Licensee is asked to submit proof to LPA of updated Infection Control Plan to reflect new facility name, phone numbers and email. In addition, Licensee will need to submit proof of liability insurance, once the new license is issued.

Based on today's pre-licensing inspection, I am recommending new license be issued.

This report was reviewed with Agustin Samaniego-Executive Director

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4