496802026-4-2-2025-21-AS-DALO-DFCVVN-20250402164636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496802026
Report Date: 04/02/2025
Date Signed: 04/02/2025 04:46:48 PM

Document Has Been Signed on 04/02/2025 04:46 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/ DIRECTOR:	CORTES, MARIA		FACILITY TYPE:	740
ADDRESS:	1397 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 526-9090
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 80	TOTAL ENROLLED CHILDREN: 0	CENSUS: 66	DATE:	04/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Gao Yang-Journey Director		TIME VISIT/ INSPECTION COMPLETED:	05:00 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 Analysts (LPAs) Alviso and Contreras conducted a Required - 1 Year visit, on 4/2/25 at approximately 9:00am, and met with Gao Yang-Journey Director. Facility has a required infection control plan, and a required emergency disaster plan. Hospice care waiver approved for thirteen(13) residents. Facility has an approved dementia plan of operation. Fire clearance is approved for 80 non-ambulatory residents, which includes 4 bedridden. Per LPAs file reviews, the facility is conducting required emergency disaster drills; On 3/17/25 fire drill, 2/13/25 fire drill, and 12/9/24 fire drill/evacuation training. On 3/27/25 the staff had an elopement drill. Training drills are done to cover staff on all shifts. LPAs reviewed ten (10) resident records. All records were complete. LPA reviewed resident (R11) medication records; LPA was provided copies of requested records. LPA obtained additional information regarding current medication orders and how medications are being provided. The LPAs reviewed ten (10) 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. LPAs toured the facility with the Gao Yang-Journey Director, and Jose Moreno-Maintenance Director. Facility was observed to be clean, orderly, and at a comfortable temperature. LPA observed all exits free and clear from obstruction. LPA observed random fire extinguishers which were serviced and tagged as required. Common areas, hallways, and bathrooms observed by the LPA had sufficient lighting available to residents in care. Continued on LIC809C...

Bethany Moellers	TELEPHONE: (707) 588-5040
Dina Alviso	TELEPHONE: (707) 588-5082
	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/02/2025

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The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility had a sufficient supply of food, water, and other emergency supplies to meet the seventy-two (72) hour shelter in place requirements. 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 instructions posted up. The facility has three generators, and emergency disaster supplies stored in case of an emergency.

Hot water was measured at 119.8 degrees Fahrenheit in memory care on the 1st floor, and 114.4 degrees Fahrenheit on facility's 2nd floor; Both hot water measurements were within regulation. Facility had a sufficient supply of cleaners/disinfectants, paper products, hygiene products, and personal protective equipment (PPE). Cleaners/disinfectants were locked up and inaccessible to residents in care. Medication rooms, in assisted living and in memory care were locked and inaccessible to residents in care. There are small refrigerators in the medication rooms which are used for any medications needing to be stored and refrigerated. Medications were stored in compliance with State and Federal requirements. LPAs observed the beauty salon to be in operation during the inspection; The salon's door has a lock to secure the beauty salon as needed/required when not staffed. All outside courtyards were clean, pathways were clear of obstructions, and had outside furnishings and shaded areas for resident use.

LPA is requesting the following documents be updated and submitted by 5/2/25.
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 by all facilities
Copy of Current Liability Insurance
Copy of current Administrator Certificate

No deficiencies cited during today's inspection.
Exit interview conducted with Journey Director Gao Yang.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

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