496803049-5-30-2023-21-AS-DALO-CSC3J6-20230530181702

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803049
Report Date: 05/30/2023
Date Signed: 05/30/2023 06:17:18 PM

Document Has Been Signed on 05/30/2023 06:17 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 FOUNTAINGROVE		FACILITY NUMBER:	496803049
ADMINISTRATOR:	BUOT, FERDINAND		FACILITY TYPE:	741
ADDRESS:	1401 FOUNTAINGROVE PKWY		TELEPHONE:	(801) 815-0808
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	322	CENSUS: 236	DATE:	05/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Ferdinand Buot-Administrator		TIME COMPLETED:	06:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Alviso, conducted a Required- 1 Year visit, on 5/30/23 at approximately 9:40am, and met with Administrator/Executive Director Ferdinand Buot, and Certified Administrator Assistant Deborah Smith. The LPA observed the front lobby entrance has a screening area for use as needed. There is a thermometer video scanner, hand sanitizer for use; There is a Concierge staff to the right as you enter the facility. The fire clearance is approved for Villetta building(1st & 2nd FL)-132 non-ambulatory, includes 8 bedridden, third floor of Villeta building 72 ambulatory only, Casitas #1 through #27, 54 non-ambulatory, and North & South buildings, 64 non-ambulatory. Hospice waiver granted for five (5) residents. The facility does have an "Emergency Disaster, and Evacuation Plan as required. The facility does have an Infection Control Plan as required. The facility does not have a dementia plan of operation. 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. The Licensee(s) of the facility are Varenna LLC, Oakmont Senior Living, and Wellquest Living LLC. LPA toured the facility kitchen with the Administrator Ferdinand Buot, Maintenance Director Dan Ferrarese, and Housekeeping Manager Norma Rudolph. 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 to meet the requirements for" 72 hour shelter in place". Continued on LIC809C....

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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

LIC809 (FAS) - (06/04)

Page: 1 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VARENNA AT FOUNTAINGROVE	FACILITY NUMBER: 496803049
	VISIT DATE: 05/30/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The facility has 14 large bins that contain required emergency supplies, and these are stored as follows: Main building has seven (7) bins total, three(3) on the 1st FL, two(2) on the 2nd Fl, and two(2) on the 3rd Fl. The South building has three (3) bins, one on each floor, and the North building has two(2) bins, one on each floor; North and South Casita's each have one large bin for each Casita area. Fire extinguishers, 207 in main bldg, 12 in North bldg, and 20 in South bldg, were all serviced and tagged as required- 4/11/2023. LPA observed all lock boxes, main bldg, North and South bldgs posted up, all have emergency set of keys. The facility vehicle keys were available in the lock box as well. LPA observed facility generators were located in each garage (3 of 3) and were working appropriately. Facility has evacuation chairs at each stairwell, Main bldg has five(5), South bldg has two(2), and the North bldg has two(2), as required, including instruction manuals for use. Hot water in the main building was checked at 116.7F and 114.6F, North building was checked at 120.F and the South building was checked at 120.F. Maintenance Director Ferrarese will monitor the hot water to ensure it is maintained at no lower than 105.F and no higher than 120.F which is within regulation. Facility had sufficient lighting in all common areas, hallways, restrooms observed, and in all buildings. The facility had sufficient supply of cleaners, hygiene products, and paper products. Toxins are locked up and secure as required. All housekeeping carts checked by the LPA during the tour were observed to be locked as required. Medications are locked and inaccessible to residents in care, including staff that don't handle medications.

LPA reviewed staff records, including training. All staff have required criminal record clearance. All staff were found to have the required first aid and CPR certification per regulations. Staff records were complete. LPA reviewed resident records. Resident records were found to be complete.

LPA reviewed emergency disaster, fire drills and evacuation drills; The following are some of the drills from 2023 & 2022: On January 25-2023 facility had an emergency flood drill, February 23-2023 power failure drill, March 31-2023 a wild fire & evacuation drill, April 26-23 a gas explosion drill, evacuation drills were conducted on March 31-22 and September 7-22. Due to the rain the 2023 evacuation drill was cancelled but has been rescheduled.
Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VARENNA AT FOUNTAINGROVE	FACILITY NUMBER: 496803049
	VISIT DATE: 05/30/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Administrator to submit updates of the following documents by 6/18/2023:
LIC 500 Personnel Summary
Copy of current RCFE Administrator Certificate
Copy of current Liability Insurance
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

At approximately 11:28 am, the LPA, and Administrator Ferdinand observed several containers left out across from the pizza oven, containers of pizza toppings, including pizza sauce, these were uncovered and left exposed; The LPA and the Administrator also observed several containers of vegetables/salad bar items in containers improperly stored, uncovered and exposed. These food items were uncovered and exposed, they were observed to be inappropriately stored in order to prevent them from potential contamination. LPA was unable to verify how long pizza food items, pizza sauce, and salad bar items had been improperly stored, and uncovered. The Administrator agreed with the food storage concerns, and started working with the kitchen Chef on a plan of correction during the LPA's inspection. LPA obtained pictures for the file. The deficiency will be cited, General Food Service Requirements 87555(b)(9)-see LIC809D.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited, see LIC809D. Failure to correct deficiency(s) by due date(s), may result in additional deficiency citations and/or civil penalties being assessed.

Exit interview conducted with Administrator Ferdinand Buot and Assistant Administrator Deborah Smith. Appeal Rights provided to the Administrator Ferdinand Buot.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/30/2023 06:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 FOUNTAINGROVE	FACILITY NUMBER: 496803049
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(9)

General Food Service Requirements 87555(b)(9) The following food service requirements shall apply: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation while touring the dining and kitchen areas with the Administrator, the facility did not ensure that pizza toppings, including pizza sauce, a variety of vegetables, and salad bar food items were stored appropriately to protect the safety and acceptability necessary to prevent contamination, which poses an immediate health, safety and/or personal rights risk to persons in care. LPA obtained photos for the file.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	License/Administrator to hold an in-service training with all kitchen staff regarding facility’s storage of food, food preparation, and food services to protect the safety and acceptability necessary to prevent contamination. Submit plan of correction in how the facility will correct the deficiency and maintain future compliance with this regulation. Proof of training to include trainer, topics, date, time spent, attendees, and employee signatures; Submit proof of training by 6/9/23. Submit plan of correction by 5/31/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4