496803049-10-16-2020-21-AS-DALO-BUG587-20201016194329

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803049
Report Date: 10/16/2020
Date Signed: 10/16/2020 07:44:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	VARENNA AT FOUNTAINGROVE		FACILITY NUMBER:	496803049
ADMINISTRATOR:	BUOT, FERDINAND		FACILITY TYPE:	741
ADDRESS:	1401 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 526-1226
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	322	CENSUS:	DATE:	10/16/2020
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Debbie Smith-Administartor		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 televideo CM Legal/ Non-compliance inspection, at approximately 2:35PM on 10/16/20, and met with Debbie Smith, Assistant Executive Director/Administrator. Executive Director/Administrator Ferdinand Buot arrived towards the end of the inspection as he was off today. A televisit/video visit was conducted due to the Covid 19 precautions; Reader is advised the LPA did not make a site visit. This facility was issued a two (2) year Probationary License as ordered by the Stipulation and Waiver: and Order (CDSS # 7218241101-F) effective 11/19/2018. LPA is conducting the inspection to review and ensure compliance with the stipulation. Deborah Smith is currently working as one of Oakmont's Varenna Administrator's and her individual probation period has started -effective 11/19/2018. Stipulation and Waiver: and Order was observed in an unlabeled binder on a display table in the entry way of the facility- this meets stipulation requirements. LPA toured the facility, by televideo, with Administrator, Debbie Smith and Maintenance director Dan Ferrarese. LPA observed that the disaster and emergency manual is located in a cabinet at the concierge desk area, location of facility emergency keys are kept in the staff mail/copy room which is in the room right behind the concierge desk area, this is open on each side to allow entry/exit from both sides. LPA observed all the necessary required keys in the lock box. The facility vehicle keys were available in the lock box as well. Facility's three story main building has evacuation chairs at all stairwells as required, 5 in total, and included two person carry/transfers instruction manuals for use. Continued on LIC809C....

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2020

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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VARENNA AT FOUNTAINGROVE	FACILITY NUMBER: 496803049
	VISIT DATE: 10/16/2020

NARRATIVE

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The emergency food supplies, including water, were observed to be sufficient. Each floor of the main building has a storage closet with emergency supplies, blankets, masks, batteries, etc that were observed to be sufficient. Hot water was checked at 107., 115.2, and 114.8 degrees Fahrenheit, which all were within regulations. All fire extinguishers in all buildings were serviced, and tagged as required on May 11, 2020.

Fire panel was inspected as well; Administrator will supply proof of service/inspection to LPA for review. Administrator will also submit elevator service inspections done in all buildings for LPA's review.

Both the two story South building, and North building, also had evacuation chairs as required, and included two person carry/transfers instruction manuals for use. Each floor of these buildings had emergency supplies, blankets, masks, batteries, etc, observed to be sufficient. Each first floor had a key lock box with emergency keys. In South building the hot water was checked at 111.7 degrees Fahrenheit, and in the North building the hot water was checked at 113.6 degrees Fahrenheit; The hot water checks in both buildings were within regulations.

LPA observed staff Jenny pull up the Robo call system records, the Robo calls are used for emergency calls and notifications sent out to all residents as needed, and required by facility's emergency plan. Jenny also pulled up the cloud based database. Facility "cloud based" database with current resident information needed for evacuation purposes including but not limited to mobility status, assistance needs and responsible party contact information. Database is remotely accessible to staff. Executive Director is signed up for emergency notifications from public safety agencies. Designated phone for the "designated person in charge" is also signed up for the emergency notifications. The phone is carried by a "designated person in charge" on all shifts. Oakmont's Community Service Team functions are to provide assistance with notifying and disseminating information to residents, responsible parties, and third party service providers such as hospice and home health providers.

The LPA will continue the CM/Legal non-compliance inspection at a later date.

No deficiencies cited today.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2020

LIC809 (FAS) - (06/04)

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