486804297-6-16-2026-21-AS-BMOS-DVCM8B-20260624092248

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804297
Report Date: 06/16/2026
Date Signed: 06/16/2026 10:20:15 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
05/04/2026 and conducted by Evaluator Star Stevenson

COMPLAINT CONTROL NUMBER: 21-AS-20260504121008

FACILITY NAME:	VACAVILLE VILLAGE SENIOR LIVING		FACILITY NUMBER:	486804297
ADMINISTRATOR:	SAMANIEGO, AGUSTIN		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(323) 902-6000
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	160	CENSUS: 76	DATE:	06/16/2026
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Agustin Samaniego-Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff do not safeguard resident's belongings

INVESTIGATION FINDINGS:

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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

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20260504121008

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VACAVILLE VILLAGE SENIOR LIVING	FACILITY NUMBER: 486804297
	VISIT DATE: 06/16/2026

NARRATIVE

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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.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

LIC9099 (FAS) - (06/04)

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