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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801225
Report Date: 02/12/2026
Date Signed: 02/12/2026 02:55:27 PM

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
10/27/2025 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20251027230602
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: 5DATE:
02/12/2026
UNANNOUNCEDTIME BEGAN:
01:42 PM
MET WITH:Azenethe Gregoire (Administrator)TIME COMPLETED:
03:10 PM
ALLEGATION(S):
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-Staff did not seek medical care for resident in a timely manner.
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 Azenethe Gregoire, Administrator.

There was an allegation of staff did not seek medical care for a resident in a timely manner. According to Reporting Party, resident (R1) was presented to the hospital at 11:41am on 10/27/2025 with concern for stroke-like symptoms and emergency personnel (unknown name) disclosed that R1's last known well was on 8:00 pm the evening prior, but the facility staff called the paramedics around 11am next day, when they noticed that R1 was not acting at their baseline leading to reporting party assumed that staff had not checked on R1 for 15 hours, or they did not seek emergency medical treatment when they first noticed their change in neuro status. Based on records, a review of medical records obtained by the Department revealed that R1 arrived at the hospital and was diagnosed with cerebrovascular accident (CVA) due to embolism of left middle cerebral artery, pressure ulcer of right buttock, stage 2 and pressure ulcer of left buttock, stage 1. Continue on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
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 5
Control Number 21-AS-20251027230602
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: 02/12/2026
NARRATIVE
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Continued from LIC9099...

LPA conducted confidential interviews with Licensee and facility staff (S1, S2 & S3) revealed conflicting information regarding the timeline and services provided to R1. LPA conducted interviews with residents (R2, R3 & R4) confirmed that staff check them regularly during night shift. According to interviews conducted by LPA with S3, R1 and all other residents were checked hourly. Per S3, the night before R1’s hospitalization, R1 was described as not engaged like R1 used to make gestures to respond to questions, but when they performed their last check at 5am, R1 was observed sleeping, breathing without any signs of distress. Investigation revealed that facility morning staff (S1 & S2) found R1 at around 7:30am when they performed their usual rounds to check on residents, R1 was observed with a significant change of condition, which prompted S1 to call the Licensee immediately. According to interviews conducted with the Licensee, the facility staff informed them about the significant change in condition of R1. Although R1 was observed with signs of distress at about 7:30am, LPA obtained Santa Rosa Fire Department records revealed that they were not contacted until they received emergency call on 10/27/25 at 11:08:54am to transport R1 to the hospital. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. Failure to seek medical care resulted in violation causing injury to person in care $500 immediate civil penalty issued. The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20251027230602
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2026
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...This requirement has not been met as evidence by:
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The Licensee agrees to develop a procedure that it will be attached to the facility plan of operation indicating how the facility will ensure that facility staff will immediately telephone 9-1-1 after learning that a resident sustain an injury or other circumstance that could resulted in an imminent threat to a resident’s health or any significant change of condition and care needs by POC due date.
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Based on interviews conducted with facility staff and records reviews of fire department service calls, the facility staff failed to seek medical attention after observing R1’s significant change of condition at 7:30am, which poses an immediate risk to the health and safety of the residents in care.
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***Failure to seek medical care resulted in violation causing injury to person in care $500 immediate civil penalty issued.
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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: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/27/2025 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20251027230602

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: 5DATE:
02/12/2026
UNANNOUNCEDTIME BEGAN:
01:42 PM
MET WITH:Azenethe Gregoire (Administrator)TIME COMPLETED:
03:10 PM
ALLEGATION(S):
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-Lack of care from staff resulted in resident sustaining pressure wounds while in care.
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 Azenethe Gregoire, Administrator.

Regarding allegation of lack of care from staff resulted in resident sustaining pressure wounds while in care. Per Reporting party, R1 have extensive pressure wounds to both of their heels and their buttocks which is concerning for possible neglect. During the course of this investigation, The Department obtained medical records indicate that R1 was taken to the Hospital and was diagnosed with cerebrovascular accident (CVA) due to embolism of left middle cerebral artery, pressure ulcer of right buttock, stage 2 and pressure ulcer of left buttock, stage 1. On 10/31/25, R1 passed away. The facility provided R1’s records including physician’s report (LIC602) dated 12/4/22, and R1’s care plan dated 12/1/24. According to physician’s report, R1 had a diagnosis of dementia, they were ambulatory, they did not have a history of skin breakdown and did not require reposition. Continues on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
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 5
Control Number 21-AS-20251027230602
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: 02/12/2026
NARRATIVE
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Continued from LIC9099A...

However, medical records revealed that R1 was bed-bound and receiving home health services for wound care since September 2, 2025. Although R1 clearly had a change of condition and ambulatory status requiring frequent reposition, the facility did not obtain an updated physician report and care plan. Furthermore, R1’s medical records revealed that on 9/10/25, R1 was transported to the emergency room with acute severe ankle problem due to a fall while they were getting out of the bath and fell twisting the left ankle, it was unclear in the after visit summary if R1’s was still ambulatory or not, but LPA reviewed incident report logs for this facility and the fall nor the hospitalization was not reported to the Department as stated in regulations. On 12/18/25 at approximate 8:56am, Licensee contacted LPA to notify the Department that R1 passed away while in the hospital after two days hospitalized due to a massive stroke. LPA inquired about reporting requirement, but Licensee stated that they have mailed the required death report, but LPA did not receive it until 1/2/26. LPA will address both deficiencies in case management. According to R1’s medical records, R1 was receiving home health services for wound care on 9/2/25, 9/4/25, 9/8/25, 9/11/25, 9/15/25, 9/18/25, 9/22/25, 9/25/25, 9/29/25, 10/2/25, 10/6/25, 10/9/25, 10/13/25, 10/16/25, 10/21/25, 10/22/25 and 10/24/25. Based on interviews conducted with Licensee confirmed that home health has been providing wound care services to R1 for the past couple of months and a nurse had been coming out normally it was once or twice a month, then visits were increased to twice a week, when skin deterioration and wounds were not getting better. Per Licensee, R1’s wounds were never staged because it started a little reddish, then it will heal, until it got to a point where they were not healing and last Friday (10/24/25), home health notified them that a wound specialist was scheduled to come on Monday (10/27/25), but R1 was not seen due to hospitalization. LPA conducted interviews with third party agency individual (I1) who confirmed that they were providing wound care services to R1 on average twice per week, the facility reported to them about R1’s pressure injuries were developing very rapidly. Per I1, R1’s wounds for one week were manageable, but the following week their wounds were significantly bad, and they were not getting better, but there were no concerns raised regarding the care or staff training that the facility provided for R1. Based on the information obtained by the Department during this investigation, the facility assisted R1 with care and reported changes of condition to the assisting agency. A finding that the allegation of lack of care from staff resulted in resident sustaining pressure wounds while in care 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: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5