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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486830735
Report Date: 10/09/2025
Date Signed: 10/09/2025 11:29:12 AM

Substantiated


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
08/20/2025 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250820123946
FACILITY NAME:VACA VALLEY LIVING A MEMORY CARE COMMUNITYFACILITY NUMBER:
486830735
ADMINISTRATOR:JAMIE HEALERFACILITY TYPE:
740
ADDRESS:80 ORANGE TREE CIRCLETELEPHONE:
(707) 724-6751
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:60CENSUS: 43DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Jamie Healer (Administrator)TIME COMPLETED:
11:43 AM
ALLEGATION(S):
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-Staff do not ensure resident's room is cleaned.
-Staff do not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Jamie Healer, Administrator.

The first allegation is about staff do not ensure resident's room is cleaned. The Reporting party provided pictures of the cleanliness of resident’s (R1) room was below optimal. On 8/10/25 afternoon, R1’s room didn’t appear that it had been cleaned at all, food was observed all over the floor, old chucks left and in their bed with dirty mattress pads. Staff arrived to barely clean the room, but it was unclear why the room and wheelchair were observed dirty. Also, it didn’t appear like staff got R1 up from bed to feed them, so they were laying on old food and other residents’ belongings were observed in the room due to another resident (R2) going into R1’s room unwanted not welcomed. On 8/23/25, the reporting party smelled bleach and observed cleaning supplies in R1’s room, which was very different from every other time when they were there and not as urine smelled like it used to be and floor was clean. Also, R1’s door was not latching, which is supporting the probability of residents are able to get into another’s room uninvited.
Continue on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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 7
Control Number 21-AS-20250820123946
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: 10/09/2025
NARRATIVE
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Continued from LIC9099...

LPA conducted a 10-day visit on 08/22/25 and subsequent visit conducted by LPA Nakagawa on 9/18/25, LPA made observations while touring the facility including the common areas and residents’ rooms were clean and well-organized. However, based on records review, LPA observed at the facility visitor’s log confirmed the presence of reporting party at the facility on both dates. Although, the facility provided their cleaning schedule for residents’ rooms including R1’s room, which is scheduled to be clean on Mondays and Laundry schedule set on Tuesdays. Housekeeping log indicates daily cleaning of waste baskets, mop and sanitize floors, vacuum clean dining room floors, tables and chairs, breakroom and their bathrooms, clean bather/room. Based on confidential interviews with housekeeping staff (S1) confirmed that they have to cover two sections that Saturday 8/9/25 in the afternoon when they were asked by facility medication technician (S2) to go over there and clean a very messy room, S1 observed crumbs on the floor, pads were messy, individual present was demanding with profanity language towards the facility to go around windows against the wall, but S1 limited to vacuum and cleaned the bathroom the most they could do, S1 described as an awkward situation, where they felt animosity and S1 explained that it wasn’t their area and they were just trying to do their best at the moment. During interviews conducted with S2 it was confirmed that they had requested S1 to come and clean the room and bathroom because it was not clean. Also, the facility provided written communication between R1’s responsible party and them including a written statement requested by them to S1, where the above information was described and signed by S1, where the facility administrator requested a meeting to be conducted with housekeeping staff on 8/19/25 indicating that this is not acceptable. LPA conducted confidential interviews on 9/25/25 with an outside agency individual (I1), who corroborated that the last time that they were at the facility on 8/8/25, R1’s room was not fully clean due to R1 experiencing a respiratory illness, they observed used napkins and tissues on the floor, so they discarded them in the garbage can. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Appeal Rights Given. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency (ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Continue on LIC9099C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 21-AS-20250820123946
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: 10/09/2025
NARRATIVE
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Continued from LIC9099C...

Regarding the allegation of staff do not safeguard resident's personal belongings. The Reporting Party provided pictures dated 8/9/25 showing their observations about resident’s (R1) personal items like their toothbrush were observed in their neighbors’ residents cup in bathroom, probably resulting in R1 using incorrect toothbrush. Also, other personal items were provided for care, and the staff were using plastic ties instead of hair ties provided. Also, half of R1’s clothing was missing, and other residents’ clothes were hanging in their closet. Based on interviews conducted with facility staff (S3), R1 moved out from the facility on 8/13/25, but there were some of R1’s belongings still present at the facility that has not been picked up by R1’s responsible party. Per S3, R1 did not have a documented property inventory on file, and they have confirmed that R2 has a history of wandering and attempting to go into other’s residents rooms including R1 due to their confusion with the similarity of all the rooms thinking that it is their own room, which S3 expressed that staff usually re-direct them to their room. Although there was no supporting evidence about missing clothing, LPA learned that on 8/09/25, R1’s responsible party noticed that R1’s dentures were missing and reported to staff. According to staff (S3), they acknowledged that R1’s dentures were missing when R1’s responsible party told them on 8/09/25, then the facility conducted a search to find out that an outside agency individual (I1) had placed the dentures in a blue container on 8/8/25, and R1 was removed from the facility on 8/13/25 with their dentures still missing. On 9/25/25, LPA conducted confidential interviews with I1, who confirmed that the last time that they observed the dentures was Friday, 8/8/25, then after the weekend they learned from the facility that the dentures went missing. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Appeal Rights Given. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. 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: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
08/20/2025 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250820123946

FACILITY NAME:VACA VALLEY LIVING A MEMORY CARE COMMUNITYFACILITY NUMBER:
486830735
ADMINISTRATOR:JAMIE HEALERFACILITY TYPE:
740
ADDRESS:80 ORANGE TREE CIRCLETELEPHONE:
(707) 724-6751
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:60CENSUS: 43DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Jamie Healer (Administrator)TIME COMPLETED:
11:43 AM
ALLEGATION(S):
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-Staff did not provided resident with adequate meal service.
-Staff over medicated resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegations listed above and met with Jamie Healer, Administrator.

Another allegation of staff did not provide resident with adequate meal service. Per reporting party, the staff lost R1’s dentures (unknown date) and never reported to R1’s responsible party, resulting in R1 had lost a lot of weight due to being unable to eat without their dentures. Based on records review, on 8/10/25 the responsible party noticed that R1 was not eating and noted missing dentures, then they proceed to report it to staff that R1 wasn't eating, where it was revealed that their dentures were missing resulting on R1 was unable to eat, and the facility never adjusted the texture of their food for them to be able to eat food. The facility provided R1’s physician report dated 6/25/25 and care plan dated 6/26/25 indicates that R1 did not have a special diet and it was suggested a regular diet bite size, soft. Based on interviews with staff (S3), they learned about missing dentures over the weekend, when they had notified staff (unknown names provided) to assist R1 with pureed food, but it was not documented due to R1 being removed from the facility on 8/13/25. Continue on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 21-AS-20250820123946
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: 10/09/2025
NARRATIVE
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Continued from LIC9099A...
LPA conducted interviews with kitchen staff who were unable to confirm or denied their acknowledgement of R1’s diet adjustment. Based on LPA’s record review and conflicting information gathered during interviews there is insufficient information to prove or disprove the above allegation regarding adequate meal service adjustment. A finding that the allegation of staff did not provide resident with adequate meal service is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Lastly, the department received an allegation of staff over medicated resident. According to Reporting Party, resident (R1) did not have a history of falls until they arrived at the facility and medication technicians including staff (S1) were sedating R1 without permission from R1’s responsible party several times in a shift with Ativan, leading to them falling more than five times in the first two weeks of them being there, where at least one fall resulted in a major injury, but when staff notified responsible party about the fall did not report nothing noticeably wrong with them. On 8/13/25 R1 was relocated to another facility, where it was discovered during a spot check of medications that Tranexamic Acid prescribed by R1’s neurosurgeon on 6/28/25 was never continued because the medication was never refilled by the facility until the day of them moving out when the facility disclosed having difficulty getting the medication, which it was confirmed during records review provided by the facility indicating that Tranexamic Acid 650mg was provided between 6/28/25 to 7/31/25, but from 8/1/25 through 8/12/25 medication not available prior authorization needed as a reason why the medication was not given as prescribed to R1; LPA will address incidental medical care deficiency on a case management inspection. Furthermore, the reporting party stated that back in July there was a follow up call with R1’s physician discussion regarding broken nose injury, where it was revealed that due to R1’s condition transportation and imaging procedures were not recommended. Based on records review, the facility provided written communication between R1’s responsible party and them including their response stating that staff who assessed R1 after the alleged major injury did not report that R1’s nose appeared broken to them, and they have notified outside agency, who told them that it didn’t appear broken either along with no pain reported from R1. Also, written statement from physician was provided to LPA indicating the following: “R1 was doing very poorly at memory care facility, they had fallen three times, and hit their face, R1 was very aggressive, hitting and kicking, not following instructions, so they were getting Ativan 0.5mg x2 in 8 hours, but then R1 was completely sedated…I reviewed photos from July 3, 2025, which showed a swollen nose and abrasions on face”.
Continue on LIC9099C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 21-AS-20250820123946
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: 10/09/2025
NARRATIVE
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Continued from LIC9099C...

Based on interviews conducted with staff (S2) R1 had increasing aggressive behavior and was hitting staff. Although there were changes to other medications (Zypresa) which it was presumed to be making R1 more aggressive attempting to stabilize behaviors, records review and staff interviews show that no medication was given without a physician’s order that supported the dosage given. There was a prescription for Lorazepam – Ativan 0.5mg take one tablet by mouth every 4 hours for agitation. In the month of August 2025 medication was given according to physician’s prescription, this allegation is unsubstantiated. A finding that the complaint allegation of staff over medicated resident is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 21-AS-20250820123946
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2025
Section Cited
CCR
87303(a)
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Type B – 87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary & in good repair at all times…Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees & visitors ***This requirement was not met as evidence by:
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Administrator agrees to submit in-service training with staff addressing areas of concern to CCL by POC due date.
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Based on LPA’s records review and interviews conducted with staff, the facility did not ensure to keep residents’ (R1) room clean, safe, sanitary and in good repair at all times which poses an immediate risk to the health and safety of residents in care.
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Type B
10/17/2025
Section Cited
CCR
87217(b)
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Type B 87217 Safeguards for Resident…Personal Property (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff… ***This requirement was not met as evidenced by:
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Administrator to ensure resident's personal property and valuables are secured according to Title 22 and facility's admission agreement. The administrator agrees to submit a written plan to ensure that this deficiency has been completed by POC due date.
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Based on LPAs record review, observation and interview the facility failed to safeguard R1's personal property (dentures) which poses a potential health and safety risk to residents 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: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7