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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108102
Report Date: 08/28/2023
Date Signed: 08/28/2023 03:37:12 PM


Document Has Been Signed on 08/28/2023 03:37 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
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:
08/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator, Paul DuranczykTIME COMPLETED:
03:45 PM
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At approximately 12:10PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Visit and met with Administrator, Paul Duranczyk. Facility is a Continuing Care Retirement Community (CCRC) and has a portion of the property licensed as a Residential Care Facility for the Elderly (RCFE). This portion of the property provides care and assistance for Older Adults in Assisted Living. Facility has an approved fire clearance and capacity for 28 Non-Ambulatory or Bedridden Residents. Facility has a Hospice Waiver for 5 individuals. Upon arrival, LPA was informed that there were currently 12 residents in care and 7 staff members on-site.

At approximately 12:30PM, LPA reviewed the Facility's Staff Roster with Administrator and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 12:50PM, LPA and Administrator reviewed a sample size of 6 staff files and 6 resident files. Staff files were all found to have First Aid and CPR certification. All Files were all found to be well organized, thorough and contained the required documentation. At approximately 2:00PM, LPA reviewed a sample size of 5 resident medication records and found that they were centrally stored and secure.

At approximately 2:45PM, LPA conducted a walk-though of the facility with Administrator and observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a mitigation plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 4 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.

Facility's fire extinguishers were found to be last inspected on 08/02/2023. Facility smoke detectors are hard wired and connect directly to the local fire station. Facility's smoke detectors, carbon monoxide detectors, and sprinkler system were last inspected on 05/05/2023. Facility's last fire drill was conducted on August 2023.

Continued on LIC809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023
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 2


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: 08/28/2023
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Continued from LIC809C

LPA requested for the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Wednesday, 09/27/2023.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC809 (FAS) - (06/04)
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