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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803049
Report Date: 06/18/2021
Date Signed: 06/18/2021 06:58:58 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 FOUNTAINGROVEFACILITY NUMBER:
496803049
ADMINISTRATOR:BUOT, FERDINANDFACILITY TYPE:
741
ADDRESS:1401 FOUNTAINGROVE PKWYTELEPHONE:
(707) 526-1226
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:322CENSUS: 236DATE:
06/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Ferdinand Buot-AdministratorTIME COMPLETED:
02:20 PM
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Licensing Program Analysts (LPAs), Dina Alviso and Karen Lopez. LPA's are conducting an 1 Year annual inspection, on 6/18/2021 at approximately 12:15pm, and met with Administrator Ferdinand Bout, and Health Services Director, Jane Torres, Debbie
Smith, Assistant Administrator, Mindy Galloway, new Health Services Director, and Jenny Latourette , Activity Director. The inspection is focused on the Infection Control procedures and practices of this facility.

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 at this time. If independent residents need care this care can be provided at any time.
LPAs toured the facility with the Administrator Ferdinand Bout, and Health Services Director, Jane Torres, Debbie Smith, Assistant Administrator, Mindy Galloway, new Health Services Director, and Jenny Latourette , Activity Director. The facility has a large supply of personal protective equipment (PPE). The LPAs observed the front lobby entrance where the screening check is conducted; There is a log book with screening questions, thermometer video scanner, hand sanitizer, and a nearby sink with soap for washing your hands. LPAs were screened before being allowed past the lobby into the rest of the facility. LPAs observed the Administrator and other staff all wearing masks as required. Fire extinguishers were tagged and serviced as required. The fire clearance is approved for Villetta bldg-132 non amb, includes 8 bedridden. third fl 72 amb. casitas #1 thru #27, 54 non amb. NO & SO bldgs- 64 non amb. Hospice granted for 5 residents.
Exit interview conducted with Assistant Administrator Debbie Smith No deficiencies cited today.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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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