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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803049
Report Date: 05/27/2021
Date Signed: 06/09/2021 11:45:26 AM



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
05/24/2021 and conducted by Evaluator Jennifer Walden
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210524143228
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:
05/27/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Ferdinand Bout (call/email)TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Provider included factors not allowed by the statutes for increasing the monthly care fees. Specifically, that Provider is not charging for optional services listed in the contract.
INVESTIGATION FINDINGS:
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Associate Governmental Program Analyst (AGPA) Walden conducted a telephone interview, on 5/27/21 at approximately 9:53AM with Administrator Ferdinand Buot.

AGPA requested specific records/documentation regarding food/dining service procedures, updated Appendix A (effective 7/15/21) and 60 day notice to residents for both items. Administrator Buot submitted all items on 5/27/21 approx. 3:10pm.

AGPA conducted a call with Witness 1 (W1) on June 1, 2021 at approx. 3:38pm about the allegations and W1 stated that she was aware of the optional items being waived and discussed “material” changes.

AGPA conducted a call with complainant (R1) on June 1, 2021 at approx. 2:00pm about the allegations and which statutes RI believed were being violated, R1 agreed that there was not a statute that community was in violation of. The concern is the items being waived and those costs eventually being allocated to the rest of the residents.

Based upon interviews with staff and residents, as well as a review of notices provided to residents as required by HSC 1788(a)(23) requiring that the provider give written notice to the resident at least 30 days in advance of any change in the resident's monthly care fees or in the price or scope of any component of care or other services, we have found the allegation to be UNFOUNDED, meaning that the allegation is false, did not happen, or is without a reasonable basis.

No deficiencies noted at this time. Copy of report provided to the facility
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Allison NakatomiTELEPHONE: (916) 531-5336
LICENSING EVALUATOR NAME: Jennifer WaldenTELEPHONE: (916) 651-8148
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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