496803049-5-23-2024-21-AS-DALO-D5K2YJ-20240523174849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803049
Report Date: 05/23/2024
Date Signed: 05/23/2024 05:48:57 PM

Document Has Been Signed on 05/23/2024 05:48 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
SANTA ROSA RO, 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:	DATE:	05/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Ferdinand Buot-Administrator		TIME COMPLETED:	06:00 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 inspection, on 5/23/24 at approximately 10:15am, and met with Administrator/Executive Director Ferdinand Buot, and Administrator Assistant Don Rodreick. The LPA observed the front lobby entrance has hand sanitizer available for use by all residents, visitors, and staff. There is a concierge staff to the right as you enter the facility;There is a sign in/sign out log at the concierge desk. 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. LPA checked random fire extinguishers, and they were marked and having been serviced and tagged-expires 4/9/25. Hospice waiver granted for five (5) residents. The facility does have an "Emergency Disaster Plan" as required. This plan is kept up in a cabinet behind the concierge desk. Emergency keys to all rooms, and facility vehicles, is kept in lock boxes hanging in the copy room, which is the room behind the concierge desk. The facility does have a required "Infection Control Plan." 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. LPA toured the facility with Norma Rudolph, Housekeeping Supervisor, and Josh Borodic, Maintenance Director. All exits in the main building, North building, and South building were observed by the LPA to be clear of obstruction. The facility has hand sanitizer available for use in all facility buildings, they are put out in different areas throughout the facility. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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

FACILITY NAME: VARENNA AT FOUNTAINGROVE	FACILITY NUMBER: 496803049
	VISIT DATE: 05/23/2024

NARRATIVE

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LPA observed all emergency disaster supplies, main building has three (3) storage areas on the 1st floor, two (2) storage areas on the 2nd floor, and two (2) storage areas on the 3rd floor. The main building has five (5) stairwells, and all had the required evacuation chair. All evacuation chairs had instructions posted up as required. The facility had food, water, and supplies to meet the "72 hour shelter in place" requirements. The kitchen had a sufficient supply of food, perishable and non-perishable. There was a sufficient supply of cleaners, paper products, and hygiene products. All housekeeping carts the LPA observed throughout the facility were locked, making all cleaners/toxins inaccessible to others/residents. The South building has three (3) emergency disaster supply bins, one (1) stored on each floor. The two stairwells had the required evacuation chair. All evacuation chairs had instructions posted up as required. The North building has two (2) supply bins, one stored on each floor. The two stairwells have the required evacuation chair. All evacuation chairs had instructions posted up as required. North and South buildings both have key storage lock boxes with emergency access keys to units in each building. North and South Casitas each have one large bin of emergency supplies stored at each site.
All medications were stored in compliance with State and Federal requirements. There is a refrigerator in the medication room, for any medications needing to be stored refrigerated. All medication logs were up-to-date and had all required information. Narcotics were double locked, and are counted every shift change, documentation was shown to the LPA. LPA observed the beauty salon to be locked, ensuring toxins are not accessible to others/residents in care. All outside courtyards were clean, orderly, and had lots of outside furnishings, and shaded areas for resident use. All pathways, walkways, and entry/exit areas were free and clear of obstruction.

LPA is requesting the following documents be updated and submitted by 6/23/24.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed by all licensees.
Copy of current Administrator Certificate

No deficiencies cited today.
The LPA will continue the annual inspection at a later date.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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