<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802026
Report Date: 06/08/2023
Date Signed: 06/08/2023 05:21:56 PM


Document Has Been Signed on 06/08/2023 05:21 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:
06/08/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Maria Cortez-AdministratorTIME COMPLETED:
05:20 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 continuation of the Annual visit, on 6/8/23 at approximately 9:40am, and met with Administrator Maria Cortez. The Required Annual visit was started on 4/28/23, see report LIC809.

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. The facility does have a required emergency disaster plan, including emergency(s) and evacuation plan. Fire clearance approval is for 80 non-ambulatory residents, which includes 4 bedridden.

LPA reviewed five(5) staff records. All staff have criminal record clearance as required by regulation. LPA reviewed staff training on file. Staff have required First Aid and CPR certification as required.

Facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. LPA observed exits free from obstruction. 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. All stairwells, two(2) of them, had an evacuation chair with instructions of how to use the chair posted up as required. Emergency bonder was observed to be up front at the concierge desk area. The storage lock box with master keys to rooms and facility vehicles to be used in facility emergencies was observed in the mail/fax room on the first floor. The facility has emergency supplies, including food and water to meet requirements of the 72 hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. LPA observed the theater room to be clean and orderly, with a movie playing. Elevator was inspected and cleared on 6/5/23. facility waiting on new permit to post up in the elevator.
Continued on LIC809C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
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 4


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: 06/08/2023
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
LPA reviewed five(5) resident records. One(1) resident lacked an updated medical assessment as required by regulation, this will be cited, 87705(c)(5) Licensees who accept and retain residents with dementia shall be responsible for ensuring that each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs, see LIC809D

During the inspection the LPA observed that the beauty salon in assisted living was unlocked with no staff inside, this left poisons/chemicals, toxins, and other items in the salon, unlocked and accessible to residents in care. This is a violation and will be cited, 87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients, see LIC809D.

During the inspection the LPA observed that the hot water checked throughout the facility, 122.F, 121.5F, and 123.4F , this is not within regulation, and will cited, 87303(e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F. and not more than 120 degree F., see LIC809D.

During the inspection, the LPA observed that two large boxes of lentils was opened and lentils were not covered and stored appropriately, a large box of rice left open and was not covered and stored appropriately to protect the safety and acceptability necessary to prevent contamination; this deficiency will be cited, 87555(b)(9) Food service requirements shall apply: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service, see LIC809D. LPA obtained photos for the file.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given to the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/08/2023 05:21 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: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2023
Section Cited
CCR
87303(e)(2)

1
2
3
4
5
6
7
Maintenance and Operation 87303€(2)
2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F . This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator to ensure the facilty's hot water heater/boiler(s) are turned down and monitor the hot water to be within regulation requirement, no lower than 105F and no higher than 120F.
8
9
10
11
12
13
14
LPA toured with the Administrator and Maintenace Director, hot water was checked on both florrs and in meory care, 122.F, 121.5F, and 123.4F , this is not within regulation.This is an immediate health and safety risk to residents in care
8
9
10
11
12
13
14
Submit a week, 5 day log, of the hot water checks by 6/15/23. Submit plan of correction by 6/9/2023.
Type A
06/09/2023
Section Cited
CCR87555(b)(9)

1
2
3
4
5
6
7
General Food Service Requirements 87555(b)(9) The following food service requirements
shall apply: Procedures which protect the safety, acceptability and nutritive values of food
shall be observed in food storage, preparation and service. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
License/Administrator to hold an in-service training with all kitchen staff regarding facility’s storage of food, food preparation, and food services to protect the safety and acceptability necessary to prevent contamination. Submit plan of correction in how the facility will correct the deficiency and maintain future compliance with this regulation. Proof of training to include trainer, topics, date, time .
8
9
10
11
12
13
14
LPA observed that two large boxes of lentil beans they were opened and were not covered and stored appropriately, a large box of rice was open and was not covered and stored appropriately;These items were not covered appropriately to protect the safety and acceptability necessary to prevent contamination; This is an immediate health and safety risk to residents in care
8
9
10
11
12
13
14
spent, attendees, and employee signatures; Submit proof of training by 6/15/23.. Submit plan of correction by 6/9/23
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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/08/2023 05:21 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: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2023
Section Cited
CCR
87309(a)

1
2
3
4
5
6
7
87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients, This requirement wasn't met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator to ensure all toxins/cleaners/chemicals and any other items that may pose a risk to residents, are locked up and inaccessible at all times. Hold an in-service with all staff regarding
8
9
10
11
12
13
14
 LPA observed that the beauty salon in assisted living was unlocked with no staff inside, this left poisons/chemicals, toxins, and other items in the salon accessible to residents in care. This is an immediate health and safety risk to residents in care
8
9
10
11
12
13
14
storage of above items. Submit proof of training by 6/15/23. Submit plan of correction by 6/9/23.
Type B
06/30/2023
Section Cited
CCR87705(c)(5)

1
2
3
4
5
6
7
Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator to ensure that all residents in memory care have required updated medical assessments, per regulations. Facility to obtain an updated medical assessment on R3;
8
9
10
11
12
13
14
LPA reviewed five(5) resident records. Resident three(R3) lacked an updated medical assessment as required by regulation. This is a potential health and safety risk to resident(s) in care.
8
9
10
11
12
13
14
Please submit a copy of resident's medical assessment by POC due date of 6/30/23.
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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4