496803049-10-19-2020-21-AS-DALO-BUK4JE-20201019190837

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803049
Report Date: 10/19/2020
Date Signed: 10/19/2020 07:11:01 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:	10/19/2020
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Ferdinand Buot-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 continued CM Legal/ Non-compliance inspection, at approximately 2:30PM on 10/19/20, and met with Ferdinand Buot Executive Director/Administrator, and Debbie Smith, Assistant Administrator/Executive Director. A televisit/video visit was conducted due to the Covid 19 precautions; Reader is advised the LPA did not make a site visit. Today this inspection is being conducted to continue the CM Legal/Non-compliance that was started on 10/16/20-see report LIC809/809C. 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 rest of the facility grounds. LPA observed all utility shutoffs, for the Main building, South building, and the North building, by televideo with Administrator, Ferdinand Buot, Maintenance Director Dan Ferrarese, and Activity Director Jenny LaTourette. All utility shut offs had the key/tool to use when needing to turn power off and/or water if needed. 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: 10/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020

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: 10/19/2020

NARRATIVE

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LPA also inspected the 6 generators on-site at the facility. One generator in each garage, Main garage, South garage, and North garage. These garage generators have transfer switch boxes connected to the generator; In the event that there is power loss to the facility, the transfer switch boxes will utilize the power from the generator to open the garage doors in an emergency and/or for use.

There were two other generators posted out in two other areas of the facility ready for use in an emergency due to the recent fire in the County, and PGE possible shut offs of electricity.

One generator was in the storage work shop, where signs identify where to locate the three (3) generators for emergency use, one of the three was here that was not in use/ready for use. LPA observed each generator, all 6 generators, with the instructions attached, and all generators worked properly as the Maintenance Director started each one up so the LPA could observe them.

Elevators were inspected on 10/6/20 in all buildings, 4 in the main building and one each in South building and North building-all passed inspection. Fire Panel in all buildings, and fire Sprinklers was inspected, 1/8/20, 1/17/20, 4/17/20, 7/23/20, and 7/24/20, all fire sprinklers and fire panels passed inspections, in the Main building, South Building, and North building.

LPA inspected additional records with Debbie Smith, Assistant Administrator Executive Director.

Fire drills are being conducted as required. Last fire drill was 9/15/20 during NOC shift. Active Shooter Emergency Disaster Drill was conducted on all three shifts, AM, PM, and NOC shift-held on 9/15/20. On July 29 during AM & PM held evacuation training. On 7/30/20 the facility held an AM Evacuation drill which met the 80% participation required; Many residents participated with some staff stand ins.

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: 10/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020

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: 10/19/2020

NARRATIVE

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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. LPA observed and saw the cloud database records. 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.

LPA reviewed 16 staff training records during today's inspection- the training met stipulation requirements. All staff had Emergency /Disaster Training, and if a staff is a designated person in charge (DPIC) that staff receives additional training to meet the requirements for that position listed in the emergency disaster plan.

Staff assigned in an emergency are to ensure that staff physically check each apartment/unit and Casita during an evacuation as outlined in the facility Emergency Disaster Manual. Residents who have additional assistance needs including those with hearing impairments have been documented so they can be given extra consideration during evacuation.

All staff have required criminal record clearance. All staff were found to have the required first aid and CPR certification per the staff position per regulations.

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: 10/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020

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: 10/19/2020

NARRATIVE

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Administrator Ferdinand Buot stated to the LPA that along with the current emergency alarm system, notification system, and their emergency disaster plan in place, they will be adding an additional notification item to this system, it is called the Visiplex. Visiplex is a form of notification that will be a speaker type vocal notification system used as needed in the event of an emergency.

The Administrator explained it is like a loud speaker(like a mega phone but louder) that will be posted outside of the facility grounds alerting residents to the emergency and whatever information administration staff are wanting to get to residents of the facility, this will be used along with robo calls, phone calls, staff going to residents units that are identified as additional assistance needed.

All items inspected by the LPA were found to be in compliance with the stipulation requirements.

There is not a date set for the installation at this time, per the Administrator it is being worked on to get everything in place to be installed at Varenna. Administrator stated he would send more information to the LPA about this System and its installation date. Administrator would also review and revise the emergency plan to reflect this added system.

No deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020

LIC809 (FAS) - (06/04)

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