210108102-7-27-2021-21-AS-FSAI-C5BS4B-20210727133228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210108102
Report Date: 07/27/2021
Date Signed: 07/27/2021 01:33:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	VILLA MARIN AMBULATORY CARE UNIT		FACILITY NUMBER:	210108102
ADMINISTRATOR:	DURANCZYK, PAUL		FACILITY TYPE:	741
ADDRESS:	100 THORNDALE DRIVE		TELEPHONE:	(415) 499-8711
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	28	CENSUS: 15	DATE:	07/27/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator, Paul Duranczyk		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Villa Marin Ambulatory Care Unit for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Chief Financial Officer (CFO), Darlene Titus. CFO summoned Administrator, Paul Duranczyk to the front. LPA toured the facility with Administrator, Paul Duranczyk. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on June 2021 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspections being conducted on May 17, 2021 (Smoke detectors), July 2, 2021 (Fire sprinklers) and July 7, 2021 (Carbon Monoxide). Carbon monoxide detectors were found to be operational during the visit. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPA toured the kitchen area with administrator and learned that there are provisions made for individuals/residents with special dietary needs. Facility kitchen has a binder with all resident’s names that might have a special need entered on a spreadsheet. Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. Facility double bedroom occupancy have bathrooms for residents which were supplied with hand soap dispensers. LPA is advising facility to ensure that residents will have individual towels that won’t be shared. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Beds were with mattress pads as required by Title 22 Regulations. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VILLA MARIN AMBULATORY CARE UNIT	FACILITY NUMBER: 210108102
	VISIT DATE: 07/27/2021

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LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the storage office located in the staff room. Staff have had all PPE training required and have been N95 Fit tested.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Paul Duranczyk.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC809 (FAS) - (06/04)

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