496803049-9-9-2021-21-AS-HDBI-C7JP4M-20211006105921

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803049
Report Date: 09/09/2021
Date Signed: 09/09/2021 03:14:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2021 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210907171128

FACILITY NAME:	VARENNA AT FOUNTAINGROVE		FACILITY NUMBER:	496803049
ADMINISTRATOR:	BUOT, FERDINAND		FACILITY TYPE:	741
ADDRESS:	1401 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 526-1226
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	322	CENSUS:	DATE:	09/09/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Debbie Smith-Assistant Administrator		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Facility is not following COVID-19 safety protocols by requiring staff to work while symptomatic

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Dina Alviso, conducted a complaint inspection, approximately 11:00am on 9/9/21, and met with Administrator Ferdinand Buot, and Assistant Administrator Debbie Smith. LPA was screened upon entry into the facility, including temperature check, and answering screening questions before being allowed to remain in the facility.

LPA interviewed facility staff, S1, S2, S3, S4,S5, S6, S7, S8 and S9, and interviewed other related various parties. LPA obtained information on facility Covid policy and procedures; The facility does have a mitigation plan in place at the facility, and the Administrator has stated to the LPA that the facility institutes the mitigation plan as needed and required. The investigation revealed that covid policy and procedures are in place and if a staff is sick with covid symptoms and/or has been notified of a covid exposure, the staff is sent home.
Continued on LIC9099C...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210907171128

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VARENNA AT FOUNTAINGROVE	FACILITY NUMBER: 496803049
	VISIT DATE: 09/09/2021

NARRATIVE

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The staff is tested for Covid by the facility Nurse before leaving the facility, scheduled to return for a Covid test or may choose to be tested by their personal Physician. Administrator stated to the LPA that the facility will continue to follow up with the staff person till they may return to work, when recovered and cleared of Covid. The facility staff interviewed all stated the above information to the LPA, and some interviewed staff stated personal experiences of when they reported Covid exposure or feeling ill while on shift, and were sent home immediately by Supervisors or the Nurse. Staff interviewed all stated to the LPA that if sick or finding out they have been exposed prior to working, they call in to a Supervisor or Nurse, report it, and are told to stay home and the need to get tested for Covid. All staff, S1 through S9, interviewed stated they have not been told and/or experienced a time when reporting to a Supervisor or facility Nurse that they were feeling sick and were made/told to work three(3) to four(4) hours symptomatic.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation, Facility is not following COVID-19 safety protocols by requiring staff to work while symptomatic, is UNFOUNDED. We have found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
No deficiencies cited during today’s visit.
Exit interviews were conducted.”

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC9099 (FAS) - (06/04)

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