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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803049
Report Date: 06/15/2026
Date Signed: 06/15/2026 06:10:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/30/2026 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20260130125255
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: DATE:
06/15/2026
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Douglas Blake-AdministratorTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff did not reappraise resident (s) in care
Staff did not regularly observe residents for changes in their condition
Staff did not provide assistance to resident in care in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 6/15/26 at approximately 12:45pm, and met with Administrator Douglas Blake.

RP alleges that "staff did not reappraise resident (s) in care”, “staff did not regularly observe residents for changes in their condition”, and "staff did not provide assistance to resident in a imely manner.

LPA reviewed resident, R1 and R2, records. LPA obtained copies of specific records reviewed. LPA reviewed documents provided by other related parties. LPA conducted interviews with staff, and other related parties regarding alleged allegations. The investigation revealed that residents, R1 and R2, were not regularly reappraised as needed per observations/changes in residents’ health condition, physical condition, etc. Residents, R1 and R2, did not have annual reappraisals as required, to ensure that residents’ current needs, if any, would be met as required. This would include obtaining updated medical information on the residents as needed, to ensure an appropriate re-assessment is completed.
Continued on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 21-AS-20260130125255
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/15/2026
NARRATIVE
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R1 moved into the facility in 2008, per record reviews, there is a medical assessment dated 9/24/2008, marked as ambulatory and independent. There is another medical assessment dated 8/24/21, marked as ambulatory but showing some activities of daily living items stating, “please assess” and “supervision assistance”. R1 is marked as not being able to handle own medications/medication equipment, having anxiety, and dysphasia. No re-assessment is on file, after this medical report of 8/24/21.

Per interviews and reviewed incidents, R1 had some incidents of observed confusion, including observed behaviors that were noticed as a change in resident's baseline/health condition. Appraisal/Reappraisals found in record review, independent upon move in, in 2008, a reappraisal plan dated 5/31/23, which has resident, being provided shower/bathing once a week. A reappraisal dated 11/21/25, no changes, showers once a week, and resident’s (R1) needs will be met by staff; Resident R1 has a private duty companion per record reviews.

Per record reviews, R2 had a medical assessment dated 11/7/2008, appraisal shows R2 as independent. In 2011 there was an appraisal marking R2 as independent and handling own medications. Medical assessment dated 11/14/25. R2 was receiving some care assistance from staff due to their terminal illness. R2 was assessed for hospice care services; Hospice care plan is dated 10/30/25. R2 handled own medications and medical equipment until they were no longer able to self-manage their medications. R2 had some fall incidents, and R2 was assessed as needed by staff and emergency personnel. R2 was admitted into skilled nursing care, and was on comfort care until their passing, on 11/15/25.

Per record reviews of pendant alarm systems log, regarding R1's calls for assistance/care needs, the log showed many dates from 1/21/26 through 4/15/26 where the pendant alarm received no response as required, which is documented numerous times in the alarm systems log. There were alarm calls noted as being responded to 15 minutes or later, per review of report log.



Per interviews with other related parties, staff would arrive 30 minutes after the alarm call and/or sometimes never arrive to provide care needed to R1. Staff could not provide proof that the alarm calls listed as not having been responded to, were responded to by staff as required.

Continued on LIC9099C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 21-AS-20260130125255
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/15/2026
NARRATIVE
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Per investigation, it is identified that reappraisals, were not obtained on residents annually and/or as needed per incidents and/or observed changes in resident (s) and/or changes in health conditions, ensuring to obtain updated medical information as needed. Per record reviews and interviews, R1 was identified as having a neurocognitive disorder, which may have been the result of the observed changes in R1, regarding incidents. Ensuring a follow-up of updated medical information, including reassessment/care plan as needed. LPA was provided the call alarm pendant log for R1's pendant; It is identified per pendant alarm systems log that some of R1's pendant calls were not answered timely and, some alarm calls were listed as not having been responded to at all, per log. Facility staff were not able to provide proof of the alarm calls having been responded to that were listed as not having a response. Per Administrator the unit has a malfunction regarding the pendant being reset.

There is sufficient information obtained to support the violations occurred regarding the allegations.

Deficiencies will be cited as follows:

87463(a)(h) Reappraisals- The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment, see LIC9099D.

87466 Observation of the Resident- The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any, see LIC9099D.

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities-To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs, see LIC9099D.



The preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.
Exit interview conducted with Administrator Douglas Blake.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 21-AS-20260130125255
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2026
Section Cited
CCR
87463(a)(h)
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87463(a)(h) Reappraisals- The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment,
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Licensee/Administrator to ensure that all residents obtain reappraisals as required, ensuring that residents all receive current care needs as required. Submit plan of future compliance with this regulation requirement by 7/10/2026.
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This requirement was not met as evidenced by: Per review of records and interviews, residents, R1 and R2 did not receive regular annual assessments and reappraisals as required, per regulations/HSC. R1 had two medical assessments on record, 2008 and 2021. R1 had a reappraisal 2008, 2023, and 2025. R2 had medical assessment in 2008, and 2025, an appraisal in 2008, and hospice care 2025. Residents did not get reappraised as required by regulations. This is a health & safety and/or a personal rights risk to residents.
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Type B
07/10/2026
Section Cited
CCR
87466
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87466 Observation of the Resident- The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any, This requirement was not met as evidenced by:
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Licensee/Administrator to ensure that all residents observed changes in condition, per regulations, are addressed in a timely manner, and residents current needs are being provided. Obtain medical updates as needed, and reappraise resident , ensuring an updated care plan is in place.
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Per investigation, it is identified that resident was not reappraised when observations in their cognitive status and behavior were observed by staff,rper incidents and interviews with staff. R1 was identified as having a neurocognitive disorder, which may have been why resident was observed with health condition changes.This is a personal rights risk and/or health & safety risk to residents.
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Submit plan of future compliance with this regulation requirement by 7/10/2026.
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: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 21-AS-20260130125255
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2026
Section Cited
CCR
87468.2(a)(4
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities-To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement was not met as evidenced by:
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Licensee/Administrator to ensure that all residents pendant alarm calls are responded to in a timely manner, and at all times. Ensure the pendant alarms system is in working order for resident's unit, ensuring all resident's care needs are being met. as required. Submit plan of future compliance with this regulation requirement by 7/10/2026.
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 LPA was provided the call alarm pendant log for R1's pendant; It is identified per pendant alarm systems log that some of R1's pendant calls were not answered timely and, some alarm calls were listed as not having been responded to at all, per log. Facility staff were not able to provide proof of the alarm calls having been responded to that were listed as not having a response. This is a risk to residents personal rights and/or to health & safety of residents.
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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: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/30/2026 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20260130125255

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: DATE:
06/15/2026
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Douglas Blake-AdministratorTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff did not prevent residents' from being financially abused at the facility
Staff transferred residents' to another facility without proper consent
Staff worked at the facility without receiving a criminal background clearance
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 6/15/26 at approximately 12:45pm, and met with Administrator Douglas Blake.

RP alleges that "staff did not prevent residents' from being financially abused at the facility, staff transferred residents' to another facility without proper consent, and staff worked at the facility without receiving a criminal background clearance". LPA reviewed resident, R1 and R2, records. LPA obtained copies of specific records reviewed. LPA reviewed documents provided by other related parties. LPA conducted interviews with staff, and other related parties regarding alleged allegations.

The investigation revealed that the individual, I1, that worked for the residents, R1 & R2, had been hired and brought in to work for them upon their admission into the facility as an office/home assistant, per irecord and inteviews. This individual, I1, was not a staff for Varenna facility and was never a hired staff by Varenna facility.
**Report amended to reflect correct allegations in second paragraph. Signed by Interim Administrator Brooke Patterson. Continued on LIC9099C..
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 21-AS-20260130125255
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/15/2026
NARRATIVE
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I1 has a criminal record clearance, per review of guardian, database of DOJ fingerprint clearances. R1 had a lunch they attended with a friend at the Villa Capri facility, which is a sister facility of Varenna, and is right below the Varenna facility. R1 had agreed to a lunch at Villa Capri willingly, and does have a right to say yes or no to luching with a friend. Per iterviews, and record reviews, there was no transfer of residence of R1 to another facility, R1 is residing in Varenna.

There is no obtained information to support violations occurred. The allegations are found to be unsubstantiated. Based on the interviews, and related information obtained during the investigation, the allegations are Unsubstantiated, meaning that although the allegation (s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur.

No deficiencies cited.
Exit interview was conducted with the Administrator Douglas Blake.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7