<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108102
Report Date: 11/08/2022
Date Signed: 11/08/2022 02:26:47 PM


Document Has Been Signed on 11/08/2022 02:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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:
11/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator, Paul DuranczykTIME COMPLETED:
02:36 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 Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Paul Duranczyk.

Facility reported an incident regarding resident, R1. Per report, R1 slid down their wheelchair onto the floor. R1 was assessed and determined to have no redness or bruising but resident did complaint of pain. Resident was x-rayed with negative findings for a fracture. Due to a persistence of pain, resident received a second x-ray which revealed a fracture. Resident did not require 1:1 supervision.

No deficiencies cited.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1