Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802026
Report Date: 08/07/2019
Date Signed: 08/07/2019 02:56:22 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:
08/07/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rosalie Sullivan-AdministratorTIME COMPLETED:
03:05 PM
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Licensing Program Analysts (LPAs) Alviso, Willis, and K. Canela conducted a case management inspection and met with Administrator Rosalie Sullivan, Oakmont staff Caroline DeGuzman, and Lizett Holvoet, Human Resources Generalist.

This is a continued case management inspection, first inspection held on 7/10/19 see LIC809/809C, being conducted to approve repopulation of the facility; 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 facility's Stipulation and Order (CDSS # 7218241101-F) effective 11/19/2018. Once the facility is approved to repopulate the stipulation and order will be in effect for Villa Capri; The Stipulation and Order is a two year probation period. The facility is subject to increased monitoring to determine full compliance with the stipulation, regulations, and governing statues.

Stipulation and Waiver: and Order was observed in the front lobby, to the left as you enter the facility, in a stand on the concierge desk - this meets stipulation requirements. LPAs obtained a photo. Administrator Sullivan stated to LPA Alviso that the stipulation and order was to remain posted at the concierge desk.

LPAs' reviewed staff training to verify that staff completed emergency disaster procedures training, and that those staff listed as disaster leaders have completed the disaster leader emergency plan training. Staff training reviewed were of all staff listed on the recently submitted Villa Capri's LIC500 personnel report.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2019
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: 08/07/2019
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Staffing schedules must be reviewed and revised as needed to meet the requirement to ensure sufficient staffing during an evacuation especially between the hours of 10:00pm and 6:00am. Villa Capri has submitted an updated personnel roster/staffing schedule. Currently there are no residents in care, and the facility will continue to review the personnel schedule as needed and ensure to revise as needed to continue to meet this requirement.

LPA notified 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 notified the Administrator that if licensing requests any documents, more clarification, and/or revisions to the emergency plan in the future the department would contact the licensee.

Facility does have fire clearance approval as required-Santa Rosa Fire Department gave fire clearance approval for 80 nonambulatory, of which 4 could be bedridden-effective 7/3/19.

LPA Alviso notified the Administrator Rosalie Sullivan that the licensee may move forward with the repopulation of Villa Capri as of todays date, 8/7/2019.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2019
LIC809 (FAS) - (06/04)
Page: 4 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026
VISIT DATE: 08/07/2019
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The listed staff on the LIC500 personnel report are the staff that will start working once the facility starts repopulating per Administrator. LPAs' also reviewed medication training for medication technicians listed on the LIC500 personnel report.

LPAs' were provided an updated LIC500 personnel report during the inspection while reviewing records. LPAs' will review all added staff to ensure required emergency training has been completed and that all staff have required criminal record clearance. Per LPAs' record reviews of required training's for specific staff were found to be complete; All staff had emergency procedures training, all medication technicians had required medication training, and all disaster leaders had disaster leader emergency plan training.

Two (2) evacuation chairs were observed, including instructions on how to use the evacuation chair, at each stairwell (2 stairwells). Maintenance/Oakmont staff showed the LPAs' how they have been trained to use the evacuation chair by three staff enacting an evacuation of a resident in the event of an emergency. LPAs' observed the emergency plan's identified assembly points (2 of 2) and signs posted at each exit. LPAs' observed the 72 hour shelter in place supplies, LPA's observed the emergency keys in a hanging lock box that can be accessed by required designated staff in the event of an emergency. LPAs' observed the facility's generator (1 of 1) with an instruction manual; LPAs' observed the generator being turned on by maintenance staff during the inspection to ensure it was working properly. All documents needing to be posted were observed by the LPAs'. The emergency plan manual was observed to be kept in the cabinet right behind the concierge's desk.

Areas noted in the Stipulation and Waiver and Order were met as follows:
Facility provided the emergency plan manual as required by the Department.
LPAs' have reviewed and observed with staff the "sharepoint program" database with sample document of resident 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.
Continued on LIC809C
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2019
LIC809 (FAS) - (06/04)
Page: 2 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: VILLA CAPRI
FACILITY NUMBER: 496802026
VISIT DATE: 08/07/2019
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LPAs' have reviewed and observed with staff the "care suite program" database that will be used for resident medications to be stored , including Dr's Orders needed for evacuation purposes, Database will be remotely accessible to staff .
Executive Director is signed up for emergency notifications from public safety agencies. LPAs observed two designated phones for the "designated person in charge" and also the "facility's driver". These phones are signed up for two emergency alert notification systems, Code Red and Everbridge, The one phone is carried by a "designated person in charge" on all shifts.
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.
LPAs reviewed the Emergency Disaster Plan as well as current staffing schedule and staff training which covers the areas required for this section.
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.
Facility has designated individuals as "Disaster Leaders" on each shift who are in charge of executing the evacuation plan. LPAs confirmed that a "Disaster Leader" is on each shift per review of the schedule provided by the Executive Director during today's inspection. 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 their home office 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. There will two evacuation drills per year that are a full simulation of an evacuation and that residents are requested to be a part of. If residents choose not be involved, facility must have "stand-ins" to constitute 80% of participants.
Continued on LIC809C...
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2019
LIC809 (FAS) - (06/04)
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