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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802026
Report Date: 04/29/2021
Date Signed: 04/29/2021 05:51:36 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 CAPRIFACILITY NUMBER:
496802026
ADMINISTRATOR:LIMBERG, STEPHANIEFACILITY TYPE:
740
ADDRESS:1397 FOUNTAINGROVE PKWYTELEPHONE:
(707) 526-9090
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:80CENSUS: 61DATE:
04/29/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Stephanie Limberg-AdministratorTIME COMPLETED:
05:35 PM
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Licensing Program Analyst (LPA) Alviso, conducted a case management- Legal/Non-compliance inspection, on 4/29/21, at approximately 3:30PM; LPA met with Administrator Stephanie Limberg by tele-video visit due to covid 19 precautions, reader is advised that the LPA did not make a site visit. This inspection is being completed to ensure compliance with the stipulation, waiver & order in place.

CDSS #7218211101-F, PER STIPULATION, WAIVER & ORDER 11/19/18, LICENSE REVOCATION, STAYED FOR 2 YEARS, PROBATION PERIOD EFFECTIVE 8/7/19 TO 8/7/21. REPOPULATION WAS APPROVED 8/7/19.

LPA did a physical plant inspection with the facility Administrator. LPA observed all exits to be unobstructed. All fire extinguishers were fully charged, serviced, and tagged 4/16/21, as required. The elevator(s) was last inspected and approved on 3/26/21. The food supply was observed to be sufficient, perishable and nonperishable. The facility has a 72 hour shelter in place food supply, and water supply; There were two large drums of water containing approximately 200 gallons each. Hot water was checked at 112.4F in a hallway bathroom, and 116.6F in a resident room. Bathrooms have required grab bars, and non-slip mats/flooring for resident use as needed. LPA observed two evacuation chairs at two separate stairwells, instructions were posted for the use of the chair. LPA observed two of three generators, and instructions for its use was near the generator. The other generator is stored in the garage used as storage area. LPA observed the medication room on the second floor where medications are centrally stored inaccessible to residents in care. LPA observed that toxins/cleaners were locked up and inaccessible to residents in care.

This case management-legal/non-compliance inspection will need to be continued by the LPA at a later date. LPA will conduct the inspection unannounced as required.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
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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