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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803905
Report Date: 06/18/2021
Date Signed: 06/18/2021 11:57:34 AM

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:ARBOL RESIDENCES OF SANTA ROSAFACILITY NUMBER:
496803905
ADMINISTRATOR:SORIANO, MARIELEFACILITY TYPE:
741
ADDRESS:300 FOUNTAINGROVE PARKWAYTELEPHONE:
(707) 566-8600
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:158CENSUS: 77DATE:
06/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mariele Soriano-AdministratorTIME COMPLETED:
12:00 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 9:00am, and met with Administrator Mariele Soriano. The inspection is focused on the Infection Control procedures and practices of this facility.
Currently the facility is having renovation work done; There is a renovation plan in place, and Administrator has a safety plan in place to help ensure residents health and safety during all renovation phases. The facility is ensuring the renovations do not impact resident services.

The facility is a licensed continuing care retirement community, consisting of an assisted living building, which includes a dementia care services area, current total resident count is seventy-seven( 77); There is a skilled nursing building on the property which has a current total count of 25 patients.

LPAs toured the facility with the Administrator Mariele, and John Caron, Maintenance Director. The facility has a large supply of personal protective equipment (PPE). The LPAs observed the front lobby entrance where the screening check in is conducted. There is a log book with screening questions, thermometer, and hand sanitizer. 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 one hundred and fifty-eight (158) non-ambulatory, of which 25 may be bedridden. All exits were observed to be clear of obstruction. LPAs observed activities being conducted in the memory care unit, and staff were setting up for the assisted living area's morning activity. Facility has a dementia plan of operation approved by the Department. The facility has an approved hospice waiver for fifteen (15) residents.

Exit interview conducted with Administrator Mariele Soriano. 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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