496802026-3-8-2022-21-AS-DALO-CCBVQV-20220308153859

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496802026
Report Date: 03/08/2022
Date Signed: 03/08/2022 03:39:42 PM

Document Has Been Signed on 03/08/2022 03:39 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 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: 52	DATE:	03/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Stephanie Limberg-Administrator		TIME COMPLETED:	03:40 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) Dina Alviso conducted a 1 year required inspection and met with Administrator Stephanie Limberg. The inspection is focused on the Infection ontrol procedures and practices of this facility. Currently 52 residents in care. Hospice care waiver approved for thirteen(13) residents. Mitigation plan submitted and reviewed by the Department. Fire clearance approval is for 80 non-ambulatory residents, which includes 4 bedridden. The Administrator notified the LPA that she is conducting random surveillance testing today with staff. The LPA toured the facility with the Administrator. Facility has sanitizer available in the entry area, and this is where all staff and visitors are screened, and temperatures taken. All screenings are logged. Facility was found to be clean, orderly, and at a comfortable temperature. LPA observed exits free from obstruction. Sufficient supply of hygiene products, cleaners, and paper products for use as needed. Sufficient food supply. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE) within the facility and in an outside garage storage. Residents have masks available to them for their use if needed and/or wanted. Administrator stated that all staff wear masks in the facility, including when providing care services to the residents in and out of the facility. Administrator had a mask on during the LPA's inspection, and all the staff the LPA observed during the inspection. The hot water is at a hot water temperature of 110.F -118.F. The LPA reviewed the hot water temperature log the Administrator sent to the LPA, and the LPA observed the three hot water boiler tanks which were all at the holding temperature of 140 which will mix with the cold water as it is delivered out to facility pipes. LPA observed the stairwells, and the evacuation chairs were in place, including the instructions on their use in an emergency. LPA observed emergency bins with all supplies stocked with listing of supplies, to be used in an emergency as needed. This supply included first aid kits, flashlights and batteries. 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: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

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

FACILITY NAME: VILLA CAPRI	FACILITY NUMBER: 496802026
	VISIT DATE: 03/08/2022

NARRATIVE

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The LPA observed the supply of emergency water held in large containers for storage and use as needed in an emergency. LPA also observed a large supply of emergency food, 72 hour shelter in place if needed in an emergency. The facility has an emergency disaster plan and staff are all trained as required per the Administrator. The LPA observed the fire extinguishers had a tag dated 3/4/2021; The Administrator has the scheduled appointment for the fire extinguishers to be serviced. The service company was scheduled to come out last friday, and didn't make it to the facility. The Administrator will provide the proof of service completed to the LPA by email as discussed. The Santa Rosa Fire Company has provided proof that they missed the scheduled appointment due to error of documented year for the inspection.

The LPA inspected the kitchen and observed many food items that were not stored properly, storing food items in a way that will help ensure the food maintains freshness, good quality, nutrition value, and ensuring that food that is no longer of good quality to consume and or serve to residents is discarded as required. LPA observed some food items to not be dated at all, and other food items to have an old date, 11/30, 1/22, including freshly made food products, creamy dressings that were made 3/2/22 and more made on 3/7/22, which the Chef stated to LPA that he will go through the refrigerated items and discard old food items and non-labled items, and will check the approximately seven(7) cream dressing containers and discard any that are of bad quality. The Administrator removed items from the refrigerator and requested the kitchen staff member to go through the food, and remove any items as discussed with them. The LPA observed a plastic bag of medications in the dementia care unit on an activity cart in the dining room; The medications turned out to be personal medications belonging to a staff person. The cart also had a bottle of nail polish remover, and a small bottle of liquid hand sanitizer. The Administrator removed all items and secured them during the inspection. The two (2)deficiencies will be cited today, Please see LIC809D.

California Code of Regulations, (Title 22, Division 6, Chapter 8) and/or Health & Safety Code, is being cited on the following 809D(s). Appeal Rights given to the Administrator Stephanie Limberg.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/08/2022 03:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VILLA CAPRI	FACILITY NUMBER: 496802026
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(9)

General Food Service Requirements

(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/09/2022
	Plan of Correction
1 2 3 4	The Licensee to submit plan on kitchen's food storage, including ensuring lableing of all stored food items and on fresh made food items, including information/training to all kitchen staff on what are the discard dates of all food items and maintenance plan to ensure food items are appropriately stored, and food items discared when required, ensuring all is done in a timely manner to help ensure health and safety of all residents in care-submit plan by 3/9/22. Submit proof of training by 3/18/22.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/09/2022
	Plan of Correction
1 2 3 4	Licensee to ensure all medications in the facility, residents and/or of staff, are locked up and secured at all times. Submit inservice-training of staff to review storage of all medications in the building, including staff's personal medications, are secured to help ensure the health and safety of all resients in care. Submit plan of completing the correction by 3/9/22. Follow up with proof of training, including all staff that attended-by 3/18/22.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC809 (FAS) - (06/04)

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