496802026-4-30-2021-21-AS-DALO-C2L4C2-20210430185825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496802026
Report Date: 04/30/2021
Date Signed: 04/30/2021 07:00:20 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 CAPRI		FACILITY NUMBER:	496802026
ADMINISTRATOR:	LIMBERG, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	1397 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 526-9090
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	80	CENSUS:	DATE:	04/30/2021
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Stephanie Limberg-Administrator		TIME COMPLETED:	03:00 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 Analyst (LPA) Alviso, conducted a case management- Legal/Non-compliance inspection, on 4/30/21, at approximately 12:45pm; 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. This is a continued case management inspection, first inspection held on 4/29/21, see LIC809/809C. The facility grounds inside and out must be in compliance regarding health and safety per title 22 regulations, health and safety code, and in compliance with the terms and conditions of the probation order. 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. Stipulation and Waiver: and Order was observed in a stand on the concierge desk - this meets stipulation requirements. All documents needing to be posted were up and observed by the LPA. The emergency plan manual was observed to be kept in the cabinet right behind the concierge's desk. LPA toured the memory care unit with the Administrator; Hot water was checked at 111.2F, and 119.6F which is within regulation. LPA discussed with the administrator to continue ensuring hot water is not below 105.F and no higher than 120.F, per regulations. LPA observed a designated mobile phone for the "designated person in charge; The phone is signed up for two emergency alert notification systems, Code Red and Everbridge, The phone is carried by a "designated person in charge" on all shifts. Executive Director/Administrator is signed up for emergency notifications from public safety agencies, Nixle, and PulsePoint. Continued on LIC809C..

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CAPRI	FACILITY NUMBER: 496802026
	VISIT DATE: 04/30/2021

NARRATIVE

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LPA reviewed and observed with staff the "care suite program" database which is used for resident medication information to be stored , including Dr's Orders needed for evacuation purposes, Database will be remotely accessible to staff.
LPA reviewed and observed with staff the "sharepoint program" database of all resident record information needed for evacuation purposes including but not limited to mobility status, assistance needs and responsible party contact information. Database is remotely accessible to staff.
Resident information will be maintained in regards to residents needs who also may have additional assistance needs during an emergency evacuation or any emergency event that may occur- This facility provides care services to residents' who need assistance with activities of daily living and/or dementia care needs.

Emergency plan states who provides assistance with notifying and disseminating information to residents, responsible parties and third party service providers such as hospice and home health providers-Oakmont staff/Community Service Team.

Facility has designated individuals as "Disaster Leaders" on each shift who are in charge of executing the evacuation plan. LPA confirmed with the Administrator that a "Disaster Leader" is on each shift. All medication technicians receive disaster leader training per the Administrator. There is a medication technician on each shift.

The main line of the facility can be directed to Licensee's home office, Administrator's mobile number or another community in order to notify residents, responsible parties and third party service providers such as hospice and home health providers. Facility has 24 walkie talkies throughout the facility in addition to land lines and cellular phones.
Emergency Disaster Plan, facility is conducting monthly Disaster Drills in order to comply with the required quarterly drill. Each staff is required to attend at least one disaster drill per quarter; Per record review, last drill, a gas explosion drill, was conducted in April 2021.

Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

LIC809 (FAS) - (06/04)

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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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VILLA CAPRI	FACILITY NUMBER: 496802026
	VISIT DATE: 04/30/2021

NARRATIVE

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There are two evacuation drills per year that are a full simulation of an evacuation and that residents are requested to be a part of. residents may choose not be involved, facility must have "stand-ins" to constitute 80% of participants; Per records, last evacuation drill was conducted 2/2021. The facility elevator was last inspected 3/26/21, and passed inspection; LPA observed the elevator clearance information. While completing a tour LPA observed the emergency plan's identified assembly points (2 of 2) and signs posted at each exit. All exits were observed to be free and clear of obstructions. Fire Panel, alarm system was inspected and approved on 7/20/2020, it is coming up on a reinspection soon. LPA observed two very large boxed containers with emergency supplies such as flash lights, batteries, etc, to be utilized in an emergency as needed. LPA observed many first aid kits, and first aid supplies to be used as needed, and in a facility emergency.

LPA observed the emergency keys in a hanging lock box that can be accessed by required designated staff in the event of an emergency. LPA observed the emergency plan's identified assembly points (2 of 2) and signs posted at each exit.

Administrator ensures sufficient staffing to meet the requirement of staffing during an evacuation, especially between the hours of 10:00pm and 6:00am. Administrator reviews and updates staffing plan as needed to ensure sufficient staffing, including ensuring staffing during an evacuation.
LPA reviewed ten (10) staff files; LPA. Per record reviews, most of the staff lacked the required emergency disaster training and/or disaster leader training. Administrator was not able to provide valid proof of the training. LPA had requested the emergency disaster plan training as required by the stipulation order, and is part of the facility's disaster plan manual that was reviewed and approved by the Department.
LPA discussed with the Administrator that if the licensee revises and/or changes the emergency plan in any way that these changes must be made known to the licensing office and submitted for the departments review and approval.

LPA will be addressing the deficiency, of staff lacking disaster plan training/disaster plan leader training to meet stipulation requirements, in the final continuation case management legal/non-compliance. This case management will be conducted in the near future, and is an unannounced inspection.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

LIC809 (FAS) - (06/04)

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