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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801225
Report Date: 03/19/2025
Date Signed: 03/19/2025 09:21:38 AM

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
02/11/2025 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250211112554
FACILITY NAME:VICTORIA'S PLACEFACILITY NUMBER:
496801225
ADMINISTRATOR:MEJIA-CHISTIAKOFF,CONCHITAFACILITY TYPE:
740
ADDRESS:2300 DONAHUE AVE.TELEPHONE:
(707) 843-0341
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 6DATE:
03/19/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Orr Chistiakoff (Licensee)TIME COMPLETED:
09:36 AM
ALLEGATION(S):
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-Staff mismanaging resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Orr Chistiakoff, Licensee.

The Department received an allegation of staff mismanaging resident's medication. Per reporting party, resident (R1) was not provided with their noon medicine on days when they attended to adult day program, their medication has been mismanaged by the facility since R1 started attending to day program between December 20th and January 22nd, 2025, resulting in R1 have experienced multiple falls injuring the resident and decreased health condition. Based on records review, R1 was prescribed with Carbidopa 25/Levodopa 100mg tab, the prescription order states to take one and one-half tablets orally four times a day to assist with movement. The facility created a medication dosage chart for medication times to the following: AM - 8:30am, Noon - 12:30pm, Evening - 4:30pm and Bedtime - 8:30pm.
Continue on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
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 2
Control Number 21-AS-20250211112554
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: VICTORIA'S PLACE
FACILITY NUMBER: 496801225
VISIT DATE: 03/19/2025
NARRATIVE
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Continued from LIC9099...

Based on interviews conducted with the Licensee and facility staff (S1) confirmed that there was a misunderstanding around the medication times determined by the facility, but it revealed that resident was indeed getting their medication four times per day as prescribed by their doctor. According to R1’s physician report dated 9/25/24, they are not able to store their own medications, which resulted in Licensee not handing them the medication to R1 to store them while they were attending to day program. Although, R1 was not dispensed with medications while they were attending to the day program, the time of the medication administration was changed, and medication was given to R1 when they arrived back from day program every day with medication times adjusted by the facility to meet doctor’s order of four times per day. The adjusted schedule reflects that R1 was taking Carbidopa at 8:30am, 3:30pm, 8:30pm and 11:30pm. A finding that the complaint allegation occurs of staff mismanaging resident's medication is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2