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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803049
Report Date: 03/29/2022
Date Signed: 03/29/2022 04:08:45 PM


Document Has Been Signed on 03/29/2022 04:08 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:VARENNA AT FOUNTAINGROVEFACILITY NUMBER:
496803049
ADMINISTRATOR:BUOT, FERDINANDFACILITY TYPE:
741
ADDRESS:1401 FOUNTAINGROVE PKWYTELEPHONE:
(707) 526-1226
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:322CENSUS: 234DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Ferdinand Buot-AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst(LPA), Dina Alviso conducted a Required- 1 Year inspection, and met with Administrator, Ferdinand Bout, Assistant Debbie Smith, and Dan Ferrarese, Maintenance Director. The inspection is focused on the Infection Control procedures and practices of this facility.

The facility is a licensed continuing care retirement community, which consists of residential assisted living residents that are provided care services, and residents that are currently independent, no provided assisted living care needs, at this time. If independent residents need care services at any time, these services may be added per the admission agreement, and the facility's plan of operation. LPA toured the main facility building with the Administrator Ferdinand Bout and Dan The facility has a large supply of personal protective equipment (PPE). The LPA observed the front lobby entrance where the screening check is conducted; There is a thermometer video scanner, hand sanitizer for use, and the Concierge will ask the screening questions and log the information as required. LPA was screened before being allowed to remain in the facility. LPA observed during the inspection, the Administrator and all other staff all wearing masks as required. Fire extinguishers were serviced and tagged as required- dated 4/18/21. The fire clearance is approved for Villetta building-132 non-ambulatory, includes 8 bedridden. Third floor 72 ambulatory, Casitas #1 thru #27, 54 non-ambulatory, and NO & SO buildings-64 non-ambulatory. Hospice granted for five (5) residents. LPA observed the food supply, perishable and non-perishable, to be sufficient during the inspection. The facility has a sufficient supply of food and water for the 72 hour shelter in place supplies. The facility has 14 large bins that contain required emergency supplies, and these are stored as follows: Main building has seven (7) bins on different floors, The South building has three (3) bins, one on each floor, and the North building has two(2) bins, one on each floor, and South and North Casita's each have one bin for each Casita area. LPA will return at a later date, to continue this inspection.
No deficiencies. No citations.
Exit interview conducted with Administrator Ferdinand Buot..
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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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