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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802026
Report Date: 04/28/2023
Date Signed: 04/28/2023 05:29:34 PM


Document Has Been Signed on 04/28/2023 05:29 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 CAPRIFACILITY NUMBER:
496802026
ADMINISTRATOR:LIMBERG, STEPHANIEFACILITY TYPE:
740
ADDRESS:1397 FOUNTAINGROVE PKWYTELEPHONE:
(707) 526-9090
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:80CENSUS: DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Eugenia Smith-Interim AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required 1-Year visit, on 4/28/23 at approximately 9:40am, and met with Interim Administrator Eugenia Smith.

Hospice care waiver approved for thirteen(13) residents. Facility has an approved dementia plan of operation. Facility has submitted the required Infection Control Plan, which is part of the facility's plan of operation. Fire clearance approval is for 80 non-ambulatory residents, which includes 4 bedridden.

Facility was observed to be clean, orderly, and at a comfortable temperature. LPA observed exits free from obstruction. LPA observed fire extinguishers, twenty-two(22), were serviced and tagged as required-expires 2/21/24. All common areas, hallways, and bathrooms seen by the LPA were observed to have sufficient lighting.

The LPA will continue this Required 1-Year visit at a later date.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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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