Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802026
Report Date: 07/10/2019
Date Signed: 07/10/2019 01:53:32 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 CAPRIFACILITY NUMBER:
496802026
ADMINISTRATOR:SULLIVAN, ROSALIEFACILITY TYPE:
740
ADDRESS:1397 FOUNTAINGROVE PKWYTELEPHONE:
(707) 526-9090
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:80CENSUS: 0DATE:
07/10/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Rosalie Sullivan-AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Alviso and Canela conducted a case management inspection and met with Administrator Rosalie Sullivan, Oakmont staff Caroline DeGuzman, and Oakmont President Courtney Siegel.

This inspection is being conducted to approve repopulation of the facility; The facility grounds inside and out must be in compliance regarding health and safety per regulations, and facility must be in compliance with the terms and conditions of the Stipulation and Order (CDSS # 7218241101-F) effective 11/19/2018.

LPAs' toured the rebuilt facility with the Administrator Rosalie Sullivan, Oakmont President Siegael, and Oakmont staff Caroline DeGuzman. Hot water measured in resident bathrooms were 117.3 , 115.7, 105.8 degrees F , which is within regulation of between 105.F and 120.F degrees. Several fire extinguishers were observed by the LPAs' to have been serviced and tagged as required. All exits were unobstructed. There was a food supply in place with sufficient perishable and non perishable food. There is a storage room that has an emergency supply of food items for the required 72 hour shelter in place in the event of an emergency. Bathrooms had required grab bars and non-slip flooring /mats in showers for resident use. LPAs observed one of the two evacuation chairs that are now set up in the facility building. There are locking medication rooms and medication carts for storing and locking resident medications ensuring they will not be accessible to future residents in care. There are storage areas/rooms for locking and keeping toxins and items that pose a risk inaccessible to future residents in care. Facility was clean and orderly during the inspection.

Continued on 809C...
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019
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: 07/10/2019
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Santa Rosa Fire Department gave fire clearance approval for 80 nonambulatory, of which 4 could be bedridden-effective 7/3/19.

The repopulation is pending approval of the Emergency Disaster Plan that will be submitted per Sue McPherson, Senior VP of Regulatory and Quality Assurance, to the Department by COB on Thursday July 11th. . Administrator gave the LPA a hard copy of the emergency plan when signing the evaluation report.

The Department will review and approve the updated emergency disaster plan per the Decision and Order dated 11/19/18.

Residents will not be allowed to repopulate Villa Capri until the plan is approved and items identified in the plan confirmed to be operational and staff trained.

LPA Alviso will be in contact with Oakmont Administrator once the emergency plan is approved and will schedule a date to return to Villa Capri, and conduct a second inspection for repopulation approval.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019
LIC809 (FAS) - (06/04)
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