Inspection Reports for Vaca Valley Living

The inspection was an unannounced complaint investigation conducted due to multiple allegations received on 08/20/2025 regarding inadequate room cleaning, failure to safeguard resident's personal belongings, inadequate meal service, and over medication of a resident.

The investigation substantiated allegations that staff did not ensure resident's room was clean and failed to safeguard resident's personal belongings, including missing dentures. Allegations of inadequate meal service and over medication were found to be unsubstantiated due to insufficient evidence. Deficiencies were cited related to maintenance and safeguarding personal property.

The complaint investigation was substantiated for allegations that staff did not ensure resident's room was cleaned and did not safeguard resident's personal belongings, including missing dentures. Allegations regarding inadequate meal service and over medication were unsubstantiated. The investigation was conducted by Licensing Program Analyst Marisol Cuadra with findings delivered to Administrator Jamie Healer.

The visit was a case management inspection conducted to cite deficiencies discovered during a complaint investigation regarding medication administration for a resident.

The facility failed to ensure that a resident was assisted with their prescribed Tranexamic Acid medication, resulting in the resident leaving the facility without the medication. The deficiency posed an immediate risk to the health and safety of the resident.

The visit was triggered by a complaint investigation related to a resident (R1) who was relocated to another facility where it was discovered that their prescribed medication, Tranexamic Acid, was not continued due to refill and prior authorization issues at the original facility.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-05-28 regarding staff not following reporting protocol, maintaining facility sanitation, providing housekeeping service, assisting with grooming, and following resident's care plan.

The investigation substantiated that staff did not follow reporting protocol by failing to provide a written incident report to the responsible party, posing a potential risk. Allegations related to facility sanitation, housekeeping service, and following the resident's care plan were found unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated regarding staff not following reporting protocol with the responsible party about incidents involving resident R1. Other allegations about sanitation, housekeeping, grooming, and care plan adherence were unsubstantiated.

The inspection was an unannounced 1-Year Required Annual Inspection conducted to ensure the health and safety of residents in care at the facility.

The facility was observed to be clean, in good repair, and odor-free with necessary safety features in place. No immediate health, safety, or personal rights violations were observed, and all reviewed resident and staff files contained the required documentation. No deficiencies were cited as a result of the inspection.

An unannounced case management inspection was conducted to confirm that staff member S1 had been removed from the facility.

The Licensing Program Analyst verified that staff S1 was terminated and removed from the facility since 08/21/2023, and is no longer present, employed, or residing at the facility. The administrator provided an updated LIC500 form confirming this.

The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff spoke inappropriately to residents.

The complaint was substantiated based on interviews with staff and residents who witnessed staff yelling or being rude to residents. Deficiencies related to violation of residents' personal rights were cited.

The complaint alleging that facility staff spoke inappropriately to residents was substantiated based on evidence gathered during the investigation.

The visit was an unannounced 1-Year Required Annual Inspection conducted to ensure the health and safety of residents in care.

The facility was observed to be clean, in good repair, and odor-free with all necessary safety features in place. No immediate health, safety, or personal rights violations were found, and no deficiencies were cited as a result of the inspection.

The inspection was conducted as a Case Management-Incident Inspection to follow up on an incident forwarded to the Regional Office on October 10, 2023.

The facility was found to be clean, at a comfortable temperature, with all exits free from obstruction. Residents were observed engaging in activities, and Resident #1's room was found to be in substantial compliance with no deficiencies observed or cited.

The visit was complaint-related, following up on an incident forwarded on October 10, 2023. No deficiencies were found during the inspection.

The inspection was conducted unannounced to investigate an incident self-reported by the facility regarding a possible theft of medications by a staff member.

The investigation confirmed missing medications and identified a staff member who appeared to be pocketing medications on video. The staff member was terminated, police were notified, and no deficiencies or citations were found during the inspection.

The complaint involved a possible theft of medications by a staff member, which was substantiated by video evidence and inventory discrepancies. The staff member was terminated and police were notified.

The visit was a case management investigation regarding a resident elopement incident that occurred on 03/25/2023.

The facility failed to conduct a headcount after the entrance alarm was triggered by resident R1's elopement. Resident R1 was found unharmed one hour later. The resident was reassessed and the care plan updated. A deficiency was cited related to safety measures for persons with dementia.

The visit was triggered by a complaint or incident report of resident R1 eloping from the facility on 03/25/2023. The resident was not previously a wander risk but was found to have dementia and unable to leave unassisted. The deficiency was substantiated and a plan of correction was required and cleared at the time of visit.

The inspection was an unannounced annual required inspection focused on infection control procedures and practices at the facility.

The facility was found to be compliant with infection control practices including COVID-19 screening, PPE availability, and staff training. A self-reported incident of suspected dependent adult abuse was discussed, but no deficiencies were cited during the visit.

The visit included discussion of a self-reported Report of Suspected Dependent Adult/Elder Abuse involving a non-staff member physically aggressive towards a resident on 01/10/2023. The incident was investigated, management intervened, and appropriate parties were notified.

Unannounced complaint investigation visit conducted in response to a complaint alleging the facility failed to report an incident of staff bringing a weapon on property.

The investigation found no violation of reporting requirements under regulation 87211. The complaint allegation was determined to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited during the visit.

Complaint allegation that the facility failed to report an incident of staff bringing a weapon on property was investigated and found to be unsubstantiated.

An unannounced complaint investigation visit was conducted in response to allegations received on 2022-03-28 regarding staff neglecting to clean a resident's maggot infested wound and improper supervision of residents.

The investigation included review of resident records, observations, and staff interviews. It was determined that wound care was managed by a home health agency and staff did not neglect wound care or supervision. The allegations were found to be unsubstantiated with no violations or deficiencies cited.

The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.

The visit was an unannounced case management follow-up to address violations identified during a prior complaint investigation regarding staff criminal clearance.

The facility permitted staff member S1 to work without obtaining the required criminal record clearance, which posed an immediate health, safety, and personal rights risk to residents. A civil penalty of $100 was issued for this violation.

The visit was a follow-up related to a complaint investigation. The complaint was substantiated as the facility allowed staff S1 to work without criminal clearance.

The visit was an unannounced office meeting to discuss various areas of concern including an increase in falls, incident reports, resident needs, and service appraisals.

No deficiencies were cited during the report. The facility has implemented a fall assessment checklist to reduce falls and update care plans. Two incidents are still under review with follow-up planned.

The visit was an unannounced follow-up to incident reports involving multiple resident falls and a specific incident involving resident R1 who was not feeling well and was taken to the emergency room.

During the visit, it was observed that staffing levels were insufficient to provide adequate supervision for residents at fall risk. Discussions were held about increasing staff presence. No deficiencies were cited during this visit, but additional follow-up with the facility is required.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2021-08-11, including staff not distributing medications as prescribed, not following residents' prescribed dietary plans, neglect resulting in a resident fall, and failure to meet residents' hygiene and incontinence care needs.

The investigation substantiated the allegation that staff were not distributing medications as prescribed, finding that 2 of 5 residents did not receive their medications as ordered, posing an immediate health and safety risk. All other allegations regarding dietary plans, hygiene, incontinence care, and neglect resulting in a fall were unsubstantiated based on observations, record reviews, and interviews.

The complaint was substantiated for the allegation that staff were not distributing medications as prescribed. Other allegations including neglect resulting in a resident fall, failure to follow dietary plans, and failure to meet hygiene and incontinence care needs were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff mismanaged a resident's medications.

The investigation found that the resident was prescribed the medication in question, which was discontinued, and there was no evidence that the medication was given incorrectly. The complaint was determined to be unsubstantiated with no deficiencies cited.

The complaint alleged that resident R1 was given medication not prescribed to them. The investigation reviewed medication records and found no medication errors or mismanagement. The complaint was unsubstantiated.

Unannounced annual required infection control inspection focusing on the Infection Control procedures and practices of the facility.

The facility was found clean, with proper COVID-19 mitigation measures in place including mask usage, social distancing signage, visitor policies, and PPE supplies. No deficiencies were cited during the visit.

Unannounced complaint investigation visit conducted due to allegations of neglect and lack of supervision resulting in residents wandering from the facility and a resident sustaining injury.

The investigation substantiated that two residents eloped from the facility's secured perimeter due to staff neglect and lack of supervision, resulting in one resident sustaining significant injury and subsequently passing away. The delayed egress alarm was not operational at the time of the incident.

The complaint was substantiated. Allegations included neglect and lack of supervision causing residents to wander from the facility and a resident sustaining injury. Evidence included interviews, police reports, medical records, and facility documentation.

The inspection was conducted as a Case Management visit with a complaint investigation regarding an obstructed facility exit door.

The inspection found that the facility exit was obstructed by a plywood board screwed into the door frame, preventing residents from exiting and causing a malfunction of the auditory alarm and delayed egress system. An immediate civil penalty of $500 was assessed.

The visit was complaint-related due to the obstructed exit door. The complaint was substantiated as the obstruction was observed and cited.

The inspection was an unannounced complaint investigation visit triggered by an allegation that a staff member forged other staff members' signatures on medical documents.

The investigation found that with one exception, all signatures on the medication administration record appeared to be written by the same person, substantiating the allegation of forged signatures. The facility's Plan of Operation requires all medication documentation to be signed by the trained staff who passed the medication. The failure to document medication passes correctly was deemed clerical in nature but posed a potential risk to resident health.

The complaint alleging staff member forged other staff members' signatures on medical documents was substantiated based on document review and staff interviews.