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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108102
Report Date: 06/24/2022
Date Signed: 06/24/2022 09:49:36 AM


Document Has Been Signed on 06/24/2022 09:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:VILLA MARIN AMBULATORY CARE UNITFACILITY NUMBER:
210108102
ADMINISTRATOR:DURANCZYK, PAULFACILITY TYPE:
741
ADDRESS:100 THORNDALE DRIVETELEPHONE:
(415) 499-8711
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:28CENSUS: 12DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Administrator, Paul DuranczykTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Villa Marin Ambulatory Care Unit unannounced for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by, Administrator, Paul Duranczyk, and was granted access into the facility.

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 2022 at the time of the inspection. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors, carbon monoxide detectors and fire sprinklers are scheduled to be inspected (See LIC 9102). 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 non-perishable foods as required by Title 22 Regulations. 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. Bathrooms were equipped with necessary grab bars, and slip resistant shower panes were present in the bathroom shower. A sample tour of resident’s bedrooms were conducted, and bedrooms inspected have lighting & appropriate furnishing as required by Title 22 Regulations.

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 Administrator office. Staff have had all PPE training required and have been N95 Fit tested. (Report continued on LIC 809C)
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VILLA MARIN AMBULATORY CARE UNIT
FACILITY NUMBER: 210108102
VISIT DATE: 06/24/2022
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LPA requested the following documents:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents

No deficiencies were cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was given to the facility Administrator, Paul Duranczyk.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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