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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803049
Report Date: 05/14/2026
Date Signed: 05/14/2026 04:46:54 PM

Document Has Been Signed on 05/14/2026 04:46 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 FOUNTAINGROVEFACILITY NUMBER:
496803049
ADMINISTRATOR/
DIRECTOR:		BLAKE, DOUGLASFACILITY TYPE:
741
ADDRESS:1401 FOUNTAINGROVE PKWYTELEPHONE:
(707) 526-1226
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 322CENSUS: 228DATE:
05/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Douglas Blake-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA), Alviso, conducted a Required- 1 Year inspection, on 5/14/26 at approximately 9:45am, and met with Administrator Douglas Blake. LPA toured the facility with Norma Rudolph, Housekeeping Supervisor, and Lawrence Whitlow, Regional Director of Maintenance.

LPA reviewed a recently received a resident (R1) incident report, and SOC341, suspected abuse report. LPA requested records regarding the incident, and records on how the resident incident was addressed, including facility's investigation into the reported incident. The Administrator agreed to submit the copies to the LPA no later than 5/20/26.

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 and do not have 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. There are three buildings, the main "Villetta" building, the North building, the South building, and twenty-seven (27) Casitas on the property.

Recent fire inspection of 4/7/2026. Nonambulatory first two (2) stories only. The fire clearance is approved for, 72 ambulatory, 250 non-ambulatory, and 8 bedridden; Total capacity is three hundred twenty-two, 322.
Capacity breakdown- 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.

Continued on LIC809C....
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/14/2026
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LPA observed the residents, total of five (5) assessed as non-ambulatory on the 3rd floor, have all vacated the units; Four (4) of the five (5) have moved to other available non-ambulatory units within the building, and one (1) resident chose to move out of Varenna. The third floor as of 5/5/26 is back in compliance with facility's fire clearance approval.

Regarding the implemented fire watch plan, required by Licensing/CCL, a re-inspection fire clearance was completed, fire clearance was approved on 4/7/26, as stated on the first page of this report. Due to the above, and 3rd floor back in fire clearance approval status, the "fire watch plan" may end as of today, 5/14/26.

The annual will continue at a later date.

No deficiencies cited during today's inspection.
Exit interview conducted with Administrator/ED Douglas Blake.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC809 (FAS) - (06/04)
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