Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802026
Report Date: 10/17/2019
Date Signed: 10/17/2019 05:59:47 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: DATE:
10/17/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Chris Mirando-Executive DirectorTIME COMPLETED:
06:10 PM
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Licensing Program Analyst (LPA) Alviso conducted a 1 year required annual inspection, on 10/17/19 at approximately 12pm, and met with Chris Mirando, Executive Director (ED).

Villa Capri is on probation; Stipulation and Order (CDSS # 7218241101-F) effective 11/19/2018. 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, on a stand to the right on the concierge desk - this meets stipulation requirements. Executive Director Chris Mirando stated to LPA Alviso that the stipulation and order would remain posted at the concierge desk.

LPA reviewed 10 staff files. LPA reviewed 10 resident files, including medication records. All resident files were complete. All staff had required criminal record clearance. Staff had current First Aid certification, and current CPR certification per regulations. All staff had required training.

LPA toured the facility with the Executive Director. LPA observed that all exits were unobstructed. All fire extinguishers were serviced per regulations. There was a sufficient food supply. 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.

Continued on LIC809C..
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2019
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: 10/17/2019
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Facility has two evacuation chairs set up in the facility building. There are locking medication rooms/ medication carts that keep resident medications locked and inaccessible to residents in care. Toxins and items that pose a risk were stored and locked away making them inaccessible tto residents. Hot water was checked at 112.6 F, 116.4 F, and 115.5 degrees F which are within regulation of no lower than 105F and no higher than 120F. 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. Facility was inspected and approved for repopulation : LPA conducted a full inspection, including reviewing and observing items listed in the facility's required emergency plan manual- see LIC 809 reports dated 7/10/19 and 8/7/2019.

No deficiencies cited in today's annual inspection.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2019
LIC809 (FAS) - (06/04)
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