Vacaville Village Senior Living

Type of visit: Case Management - Incident

At approximately 11:15 AM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to follow up on self-reported incident with Resident (R1) that was submitted to Community Care Licensing on 09/08/2026, as a result of an incident that occurred on 09/02/2026. LPA made observation and obtained documents. No citations are deficiencies are being cited.the state’s words, verbatim · CDSS document, Sep 10, 2026

Allegation investigated: Staff do not safeguard resident's belongings

On 06/16/2026 Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to deliver complaint findings of a complaint received by Community Care Licensing (CCL) on 05/04/2026 in which complainant (R1) alleged that, complainant let staff know they had a couple of items go missing including a bedsheet and phone charger and was told by the staff member that “nothing could be done about it.” An interview with R1 had R1 recalling that a yellow or orange phone charging cord went missing, as well as a specific patterned bed sheet they owned. When R1 was asked who they thought might have taken the two items, R1 replied that that did not have an idea as to who might have taken the items. In addition, when asked how much the phone charging cord and bedsheet might have been worth R1 was not sure. Interviews with four (4) staff members revealed no evidence of theft from R1. In addition, interviews with three (3) residents returned no concern for theft or potential for theft at the facility. Continued on LIC9099-C Unsubstantiated Continued from LIC9099 LPA obtained a copy of the posted Theft and Loss Prevention Program at the facility, as well as a copy of the loss policy referencing Health and Safety Code 1569.152-154 on the requirements for RCFE’s to have a policy for Theft and Loss steps to take. Because R1 was unsure who might have taken the smaller items and because interviews with staff and residents returned no concern for theft or the potential for theft at the facility, the above allegation is unsubstantiated. A finding that the complaint allegation is Unsubstantiated means 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. Exit interview conducted. Copy of report discussed and provided to Agustin Samaniego-Administrator whose signature here denotes receipt.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 21-AS-20260504121008

Allegation investigated: Personal Rights

On 06/16/2026 Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to deliver complaint findings of a complaint received by Community Care Licensing (CCL) on 05/04/2026 in which complainant alleged that, “staff have attitudes and act like they don’t care about the residents” with complainant further indicating that, “staff don’t speak to complainant and are always on their phones” Upon interviewing complainant, LPA learned that their concern for “attitude” and lack of concern for residents is mostly isolated to one staff member, S4, rather than a systemic issue with all staff at Vacaville Village Senior Living. During a visit to Vacaville Village Senior Living, LPA learned that upon arrival to the facility, all care staff are required to pick up a company iphone that has the facility-wide call light alert system loaded on mobile phones. It is from these iphones that staff get alerts about who needs help in other rooms and that residents will often see caregivers looking at the company iphone when alerts for help pop up. On 06/04/2026 LPA received a copy of a “Cell Phones/Cameras/Communication Devices and Breaks at Work” document signed by S4 on 04/15/2026 that advises, employees should not be using their personal phones or devices at work. Continued LIC9099-C Unsubstantiated Continued from LIC9099 In addition LPA obtained copies of the Employee handbook where on page 51 of 64 it indicates that making or taking personal calls of more than three (3) minutes is not allowed, page 48 of 64 of the same handbook indicates employees are to be polite, courteous…attentive to every customer…that Residents come first and that Residents are to be treated courteously and always given proper attention. Additional interviews with three random residents had residents R1, R2, R3 raising no concern for staff “attitudes” or staff lacking concern for residents or of staff were constantly on the phones while working. Finally LPA obtain a signed copy of “Conduct Expectations” signed by S4 acknowledging that professional, courteous and polite conduct is required at all times and acknowledging that disciplinary or corrective actions could be taken against employees who fail to maintain a positive, kind, welcoming attitude toward others or those that use personal phone, or other entertainment devices during work time. In addition, the Conduct Expectation document forbids employees to use personal devices (phones or cameras) for making or receiving personal calls or texts that are not work-related during work time, and well as, violating Residents Rights like neglect or failing to answer call lights. Because of conflicting information about the concern that staff show for residents and because staff use a company owned iphone call light alert system, the above allegation is unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Exit interview conducted. Copy of report discussed and provided to Administrator Agustin Samaniego whose signature here denotes receipt.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 21-AS-20260504121008

Allegation investigated: Facility does not have adequate staffing to meet resident care need

At approximately 10:00 AM, Licensing Program Analyst (LPA) Star Stevenson arrived to deliver findings of a complaint received by Community Care Licensing (CCL) on 03/10/2026 and was greeted by Wellness Director- Elizabeth Aguiar. The complaint alleges that R1, who requires the help of 2 simultaneous caregivers for transfers had the help of just one caregiver on the NOC shift of 03/08/2026 or 03/09/2026 and that staff (S9) had “6 more calls for service while helping R1.” The complainant further stated that Vacaville Village Senior Living (facility) “routinely hire employees who quickly quit and as a result the facility is chronically understaffed.” Records obtained by CCL indicate that at the time of the complaint the facility had 77 residents, 12 of whom required 2-person assist with Hoyer lift or other transfers, while 12 of the 77 residents were receiving hospice care. Continued on LIC9099-C Substantiated Continued from LIC9099 Interviews with S1, S2, S3, S4, S5,S6, S7, S8 all report an established history of new employees being hired and quitting weeks after being hired or never showing up for their first day of work, as well as, a documented history of frequent and/or sudden call-offs where employees do not show up to work without warning, on weekends for example. Observation of payroll records and staffing schedules revealed that on NOC shift (10:00PM to 6:00 AM) from 03/09/2026 to 03/10/2026 just one (1) Med-Tech and two (2) Caregivers were left to care for Assisted Living residents, including twelve (12) of which required 2-person simultaneous assistance. An interview with S6 indicated that “being down to 1 Med-Tech and 1 Caregiver happens on a week-to-week basis, about 2 days out of 5 and that makes it really bad when getting residents ready for bed, toileting etc”. Separate interviews with S7, and S8 also indicated use of just 1 Med-Tech and 1 Caregiver at times for Assisted Living residents. In addition, an interview with S2 indicated that being down to just one Caregiver and a Med-Tech on NOC shift, “was pretty common, that has happened maybe 10 times in the last month” (mid-February to mid-March 2026) Finally, a review of call light response time on one day of 03/09/2026 revealed a record of four (4) calls for help requiring more than thirty (30) minutes to respond, twenty-six (26) requiring more than fifteen (15) minutes to respond and thirty (30) requiring more than then (10) minutes to respond. Based on interviews and record review it appears the facility does not have sufficient staffing; therefore the allegation that Licensee does not ensure facility is adequately staffed to meet residents needs is Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A type B citation for violation of California Code of Regulations (CCR) 87411(a) which requires personnel shall at times be sufficient in numbers…to meet residents needs. (See 9099-D page) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit Interview Conducted.the state’s words, verbatim · CDSS document, May 12, 2026 · control 21-AS-20260310131139

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 26, 2026

87411(a) Personnel Requirements - General Facility personnel shall at times be sufficient in numbers, and competent to provide the services necessary to meet resident needs: This requirement is not met as evidenced by: Based on interviews and record review facility did not have staffing in sufficient numbers to provide for care as written in both physican assessments and care plans for 77 residents, 12 of which required 2 person assist.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Licensee and Administrator will provide documentation of review of California Code of Regulations (CCR) 87411(a) which requires personnel shall at times be sufficient in numbers…to meet residents needs. In addition, licensee will identify on-going steps/measures to hire and retain staffing sufficient in numbers to meet residents needs and provide a list of these steps to community care licensing by Plan of Correction due date 05/26/2026

Allegation investigated: personal rights

At approximately 09:45 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver complaint findings for a complaint received by the department on 04/01/2026 in which it was alleged that a personal rights violation occurred in which the personal privacy of a Resident of Vacaville Village had been violated. The complaint alleged that a, “serious concern regarding Resident privacy at Vacaville Village Assisted living” had occurred and that on “March 31, 2026, a photo was posted on a staff member’s personal Facebook page that appears to show a Resident, with a staff member visibly wearing a company (Vacaville Village Senior Living) name tag, which directly associates the post to the facility” Record review by Community Care Licensing (CCL) revealed that Resident (R1) had moved out on in May of 2025 and an interview with staff member (S1) revealed that the photo in question was taken by the family (W1) at the private residence of R1 in late November or early December 2025 and that R1 was no longer a Resident of Vacaville Village Senior Living Continued on LIC9099C Unsubstantiated continued from LIC9099 In addition, observations of LPA revealed that the room in the photo shared by the complainant was not the same room that R1 lived in while at Vacaville Village Senior Living (photos on file) An interview with S1, did reveal that S1 was wearing their work badge from Vacaville Village Senior Living, but review and magnification of the provided complaint photo does not appear to reveal the details of the badge. Because R1 was not a Resident at the time the potential privacy violation might have taken place and because analysis of the photo revealed the location to be outside the room R1 lived in at Vacaville Village Senior Living and because it is unclear if the details of S1’s work badge can be made out , the allegation the privacy of a resident at Vacaville Village Senior Living having been violated is UNSUBSTAINTIATED. A finding of unsubstantiated means, 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 Report was reviewed with Administrator whose signature here denotes receipt.the state’s words, verbatim · CDSS document, Apr 20, 2026 · control 21-AS-20260401163236

Allegation investigated: Staff not following care plan when assisting resident with ADLs

At approximately 11:45 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver complaint findings for a compliant received by the department on 01/20/2026 in which it was alleged that staff were not following the care plan when assisting a resident (R1) with ADLs. In the complaint, it was alleged that staff person (S1) had their foot run over with a Hoyer Lift while performing a transfer on a resident who requires 2-persons assist with transfers. The complainant indicated, “they were unaware if R1 sustained any injury or whether R1 remained suspended in a (Hoyer Lift) sling during the incident”. The complainant suggested that the “incident reflects a serious safety concern related to improper Hoyer lift use and noncompliance with established two-person assist protocols” The department obtained records, made observations and conducted interviews. Interviews with witness one (W1), S1, S2 and S3 revealed that use of a Hoyer Lift was not involved in incident that ultimately led to the foot of S1 being run over and that, in fact it was the main wheel of a power wheelchair that ran over S1’s foot. Furthermore, a review or R1’s Physician Report (LIC602) indicates both, “Wheelchair dependent” and “assistance to move” (with a wheelchair). Continued on LIC9099-C Unsubstantiated Continued from LIC9099 Interviews with S1, S3 and W1 revealed a lack of clarity about who ultimately pressed the joystick of the power wheelchair to run S1’s foot, but an interview with W1 indicated that family made several attempts to fix the joystick control of the wheelchair themselves, noting that the control joystick was loose and that the company that provided the wheelchair had been “called multiple times to fix it” and that the family of R1 was considering getting a new power wheelchair for R1. W1 also indicated that the family wanted to remove the power wheelchair from the facility but then R1 became hospitalized for a separate issue, noting that a manual wheelchair for use continued to be in R1’s room. Because R1 was noted to be “wheelchair dependent” and needed, “assistance to move” (the wheelchair) by Physician’s Report and because a Hoyer Lift transfer was not involved in the incident, the allegation of “Staff not following care plan when assisting residents with ADLs” is UNSUBSTAINTIATED. A finding of unsubstantiated means, 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 occurthe state’s words, verbatim · CDSS document, Feb 5, 2026 · control 21-AS-20260120091821

Type of visit: Prelicensing

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 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 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 Directorthe state’s words, verbatim · CDSS document, Dec 30, 2025

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of Ownership Capacity: 160 Census (if any clients in care): 81 COMP II Participants: AGUSTIN SAMANIEGO, STEVEN ATLAS Interview Method: Telephone interview On August 06, 2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Aug 6, 2025