486830735-3-23-2022-21-AS-HDBI-CD7TRC-20220405145717

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486830735
Report Date: 03/23/2022
Date Signed: 03/23/2022 02:27:48 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/19/2021 and conducted by Evaluator Katrina Walters

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20211119115327

FACILITY NAME:	VACA VALLEY LIVING A MEMORY CARE COMMUNITY		FACILITY NUMBER:	486830735
ADMINISTRATOR:	JAMIE HEALER		FACILITY TYPE:	740
ADDRESS:	80 ORANGE TREE CIRCLE		TELEPHONE:	(707) 724-6751
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	60	CENSUS: 48	DATE:	03/23/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jamie Healer, Administrator		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Neglect/lack of supervision resulted in resident in care sustaining pressure injury
Neglect by staff resulted in injury of resident

INVESTIGATION FINDINGS:

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On this date Licensing Program Analyst (LPA) Walters arrived unannounced for the purpose of delivering the findings for this complaint, regarding the above-mentioned allegations, and met with Administrator, Jaime Healer.

On 11/19/2021, The department received a complaint alleging the following: Neglect/lack of supervision resulted in resident in care sustaining pressure injury and neglect by staff resulted in injury of resident. LPA investigated this allegations by observation, interviewing staff and reviewing resident and staff documents, which include: time sheets, resident Physician Reports (LIC 602), Needs and Service Appraisals and ID sheet. From this the following determinations were made:

Continued on 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

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-20211119115327

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: VACA VALLEY LIVING A MEMORY CARE COMMUNITY	FACILITY NUMBER: 486830735
	VISIT DATE: 03/23/2022

NARRATIVE

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Continued from 9099

Allegation- Neglect/lack of supervision resulted in resident in care sustaining pressure injury. LPA interviewed the home health nurse for R2 and staff, reviewed time sheets, resident's Assisted Daily Living Logs (ADL), Home Health notes, Progress and daily shower logs. File review and interviews indicates that upon admission resident R2 was identified as being non-ambulatory, but at some point became unable to bear weight. Staffing progress and charting notes indicate that staff were providing assistance with daily hygiene needs and identified a rash on 9/15/21. Facility requested home health services for R2. Home Health initiated 9/26/21, and on 10/8/22 the home health nurse who assessed resident noted that they were treating resident for a rash. Due to conflicting statements and documentation of hospice agency. LPA is unable to determine whether resident sustained a pressure injury. Therefore the allegation is UNSUBSTANTIATED.

Allegation- Neglect by staff resulted in injury of resident. LPA interviewed staff and reviewed records. File review indicates that resident R3 was identified as being a fall risk by their hospice agency and encouraged that safety precautions be in place. Per interviews with staff, resident had a one on one personal staff during the day, and was encouraged to join activities. During the NOC shift, records indicate that R3 received hourly checks. Interviews also reveal that during the alleged incident, R3 was engaged in activities and surrounded by other residents and staff. Therefore this allegation is UNSUBSTANTIATED.

A finding that the complaint allegations: Neglect/lack of supervision resulted in resident in care sustaining pressure injury and Neglect by staff resulted in injury of resident was unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegations occurred.

No deficiencies cited during this visit.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC9099 (FAS) - (06/04)

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