496803049-11-18-2020-21-AS-CMAZ-BVX3X6-20201202173749

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803049
Report Date: 11/18/2020
Date Signed: 11/18/2020 04:45:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2020 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201019194145

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:	11/18/2020
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Ferdinand Bout-Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Resident council are not receiving timely responses from the Licensee
Facility’s emergency plan/ notification system does not meet regulations

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a tele-video visit on 11/18/20 at approximately 3:45PM. LPA spoke with Executive Director (ED)/Administrator Ferdinand Buot. The inspection is being conducted by tele-inspection due to COVID-19 precautions. The reader is advised that the LPA did not physically make a site visit.

LPA interviewed two (2) facility staff (S1 and S2), six (6) residents, and other various parties during this investigation. LPA reviewed the Stipulation and Waiver and Order (CDSS # 7218241101-F) effective 11/19/2018, specifically section “B 1-9, D, E, and F”. LPA reviewed the most recent case management inspection, LPA recently completed an inspection on October 16th, and 19th, 2020 reviewing the facility’s compliance with Stipulation requirements as well as past case management inspections. LPA reviewed the facility’s Emergency Plan/Disaster Manuel against the requirements to be met in the Stipulation. LPA reviewed other documents provided regarding resident council requests, and the facility’s response to those requests. See the following:
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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20201019194145

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/18/2020

NARRATIVE

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B1 – Stipulation and Waiver and Order (CDSS # 7218241101-F) effective 11/19/2018 states “A system for maintenance of readily-accessible current information about the status of all residents for evacuations purposes, including current information about which residents are non-ambulatory, bedridden, and/or unable to leave the facility without assistance…” and B2 – “A mechanism to reasonably ensure the accessibility of all information required to be readily available to facility staff in case of an emergency…” The Licensee has a "cloud" database with current resident information needed for emergencies/evacuation purposes. The function of the “cloud” database includes but is not limited to information regarding resident’s mobility status, assistance needs and responsible party contact information. This database and the resident information are remotely accessible to staff and by staff.

B3 – Stipulation and Waiver and Order (CDSS # 7218241101-F) effective 11/19/2018 states “A method whereby the facility’s administrator and designated substitutes received real-time emergency notifications from public safety agencies so that such information can be disseminated to on-duty staff.” The Licensee, ED and designated substitutes are signed up for emergency notifications from public safety agencies, Nixle, and SoCoAlert. LPA observed a designated phone for the "designated person in charge" and confirmed emergency notifications application is loaded on the phone. The phone is carried by a "designated person in charge" on all shifts. All staff and residents with personal cell phones are encouraged to sign up for the public safety agency alerts if able.

B4 – Stipulation and Waiver and Order (CDSS # 7218241101-F) effective 11/19/2018 states “Procedures periodically confirming the location and status of each resident after an event that results in the implementation of the emergency evacuation plan if the resident has not returned to the facility…” and B5 - “A clear protocol for notifying residents’ responsible parties or family members during evacuation, if reasonably practicable…” Administrator and Regional Vice President of Operations explained the function of the Community Service Team, this Team provides assistance with notifying and disseminating information to residents, responsible parties and third-party service providers such as hospice and home health providers in a facility evacuation/emergency/relocation. Resident information and resident emergency contact Information accessible to staff by the ‘cloud’ database” .
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SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20201019194145

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/18/2020

NARRATIVE

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B6 – Stipulation and Waiver and Order (CDSS # 7218241101-F) effective 11/19/2018 states “A written description of the role and responsibility of the facility’s administrator and designated substitutes with regard to emergencies…” Administrator and designated substitute roles and responsibilities are documented, and in the emergency plan. The facility has a qualified substitute at all times on-site as required

B7 – Stipulation and Waiver and Order (CDSS # 7218241101-F) effective 11/19/2018 states “Where audio and visual alarms are absent, an alternative method shall be developed and submitted to the Department for review and approval whereby all facility residents would be notified of the need for evacuation of the entire facility, including independent living and casita residents, with consideration given to the likelihood that residents may have hearing impairments.” The Department approved the alternate method developed by the facility. The facility staff physically checks each apartment and casita during an evacuation to ensure it is empty as outlined in the facility Emergency Disaster Manual. The assigned staff will also go through the areas in a golf cart with a bull horn to announce the notification of emergency/evacuation to all residents in the casitas. Residents who have additional assistance needs including those with hearing impairments have been documented so they can be given extra consideration during an evacuation as required. Facility emergency notifications are used along with physically checking each unit/casita per the emergency plan.

B8 - Stipulation and Waiver and Order (CDSS # 7218241101-F) effective 11/19/2018 states “Designation of a staff position at each site to be in charge of safety and security.” Licensee has the ED on-site as a staff position in charge of safety and security. The facility also has designated individuals as "Disaster Leaders" on each shift who are in charge of executing the evacuation plan. LPA confirmed with the Administrator that a "Disaster Leader" is on each shift per review of the schedule provided by the Executive Director during inspections and review of staffs training.

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SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20201019194145

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/18/2020

NARRATIVE

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B9 – Stipulation and Waiver and Order (CDSS # 7218241101-F) effective 11/19/2018 states “A process for communicating with residents, families, hospice providers and others during an evacuation or other disaster where the facility shelters in place, as appropriate, that shall include the use of landlines, cellular telephones, or walkie talkies throughout all facilities…” During an evacuation, disasters, or sheltering in place, per Regional Vice President of Operations, and the Administrator, the main line of the facility can be directed to the home office or another community in order to notify residents, responsible parties and third party service providers such as hospice and home health providers. Facility has walkie talkies throughout the facility, in addition to numerous landlines, and cellular phones. Other notifications used are Robo calls, Facebook, Posting on Oakmont website,

D & E- Staffing schedules to ensure sufficient staffing during an evacuation especially between the hours of 10:00pm and 6:00am. Met by the Emergency Disaster Plan with current sufficient staffing schedule, and staff training which covers the areas required for this section. LPA has reviewed the staff training including those individuals designated as "Disaster Leaders."

F - Per ED and LPA’s review of the Emergency Disaster Plan, facility is conducting monthly Disaster Drills in order to comply with the required quarterly drill. Each staff is required to attend at least one disaster drill per quarter. There are two evacuation drills per year that are a full simulation of an evacuation and that residents are requested to be a part of. If residents choose not to be involved, facility must have "stand-ins" to constitute 80% of participants. Fire and evacuation drills were reviewed and documented in last inspection.

Interviews revealed that notifications were sent to residents regarding the recent fires, Shady, LNU, and the Kincade. Residents all stated that they were notified and kept updated about evacuations, and possible evacuations. Residents stated that staff sent them Robo calls, and informational letters discussing evacuations, and possible evacuations, what to pack to be ready, and where residents would relocate to. Residents stated that there were busses parked out front of the facility in case the facility evacuated. Per file reviews and observations by the LPA, the Stipulation is being complied with by the Licensee. The investigation revealed the facility has complied with Section B1-9, D, E, and F.
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SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20201019194145

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/18/2020

NARRATIVE

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Additionally, the ED has provided information on an additional alert feature the Licensee is choosing to install over the next couple months, once installed the ED will update the Emergency Plan. The Visaplex PA and Notification system, consists of outside and inside speakers, with a battery backup that will alert residents on campus of an emergency. In a power outage the Visaplex speakers can work for two hours in active use, and 48 hours stand by. Per the Administrator, the approximate date of Visaplex installation is 11/15/20. There will also be an installation of wireless visual alert devices in the casitas area-estimated completion is 12/20/20 per Administrator.

The facility has a Fire Life Safety Monitor for Varenna, for the next five years, who was assigned by the County of Sonoma. The Fire Life Safety Monitor is assigned to monitor and evaluate on a monthly basis Varenna’s fire life safety plan/emergency disaster plan and discuss any suggestions for enhancing communication. The ED submits copies of the Fire Life Safety Monitors report as requested by the Department. The initial report was received on October 19, 2020.

With regards to the allegation of “Resident council is not receiving timely responses from Licensee”. LPA reviewed resident council documents received, and interviews with various parties regarding response to resident council requests, indicate the facility has responded in writing regarding any action or inaction taken in response to resident council concerns/recommendations within 14 calendar days per Health and Safety code.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations, Resident council are not receiving timely responses from the Licensee, and Facility’s emergency plan/ notification system does not meet regulations, are UNFOUNDED. We have found that the complaint allegations were unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
No deficiencies cited during today’s visit.
Exit interviews were conducted.”

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020

LIC9099 (FAS) - (06/04)

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