496802026-5-21-2024-21-AS-DALO-D5H2GR-20240521172335

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496802026
Report Date: 05/21/2024
Date Signed: 05/21/2024 05:23:42 PM

Document Has Been Signed on 05/21/2024 05:23 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 CAPRI		FACILITY NUMBER:	496802026
ADMINISTRATOR:	CORTES, MARIA		FACILITY TYPE:	740
ADDRESS:	1397 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 526-9090
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	80	CENSUS: 64	DATE:	05/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Maria Cortes- Administrator		TIME COMPLETED:	05:35 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) Alviso conducted a Required - 1 Year visit, on 5/21/24 at approximately 12:35pm, and met with Administrator Maria Cortes. Hospice care waiver approved for thirteen(13) residents. Facility has an approved dementia plan of operation. Facility has a required infection control plan, and a required emergency disaster plan. Fire clearance approval is for 80 non-ambulatory residents, which includes 4 bedridden. The facility is holding monthly emergency drills, including an evacuation drill; On 3/13/24 an evacuation drill was completed on each shift; Facility understands quarterly drills are to be held, one an evacuation drill, and all drills held on each shift. LPA reviewed eight (8) resident records. All records were complete. The LPA reviewed seven (7) staff records. All staff have criminal record clearance as required by regulation. LPA reviewed staff training records. All staff had required training. Staff have First Aid and CPR certification as required. In review of staff records, LPA observed that the facility hired a staff person that has a class B driver's license, and they can legally drive the facility's vehicle/bus to use for resident activities and/or scheduled transportation, per facility's plan of operation. LPA toured the facility with the Administrator Maria Cortes, and Maintenance Director Jose Moreno. Facility was observed to be clean, orderly, and at a comfortable temperature. LPA observed exits free from obstruction. LPA observed random fire extinguishers which were serviced and tagged. Common areas, hallways, and bathrooms observed by the LPA had sufficient lighting available to residents in care. The LPA observed some residents having their lunchtime meal in the dining room. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility had sufficient supply of food, water, and other emergency supplies to meet the seventy-two (72) hour shelter in place requirements. The facility has three generators, and emergency disaster supplies stored in case of an emergency. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VILLA CAPRI	FACILITY NUMBER: 496802026
	VISIT DATE: 05/21/2024

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
26
27
28
29
30
31
32

The storage lock box with master keys to rooms and facility vehicles to be used in facility emergencies is in the mail/fax room on the first floor. LPA observed that each stairwell, two (2) had required evacuation chairs, with instruction posted up. Facility had a sufficient supply of cleaners/disinfectants, paper products, hygiene products, and personal protective equipment (PPE).

Hot water was checked at 119. degrees Fahrenheit which is within regulation. Laundry rooms had no cleaners/toxins accessible to residents in care, and the rooms were clean and orderly. Medication rooms, in assisted living and in memory care were locked and inaccessible to residents in care. All medications were stored in compliance with State and Federal requirements. There are refrigerators in medication rooms, for any medications needing to be stored refrigerated. LPA observed the beauty salon to be locked, ensuring toxins are not accessible to residents in care. Cleaners/toxins were locked up and inaccessible to residents in care. All outside courtyards were clean, orderly, and had lots of outside furnishings, and shaded areas for resident use.

LPA is requesting the following documents be updated and submitted by 6/21/24.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed
Copy of Current Liability Insurance
Copy of current Administrator Certificate

There are no deficiencies cited during today's visit.
Exit interview conducted with Administrator Maria Cortes.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2