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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803905
Report Date: 03/08/2022
Date Signed: 03/08/2022 05:53:15 PM


Document Has Been Signed on 03/08/2022 05:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:152CENSUS: 63DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Mariele Soriano-AdministratorTIME COMPLETED:
05:55 PM
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Licensing Program Analyst (LPA), Dina Alviso conducted a 1 Year required inspection and met with Administrator Mariele Soriano. This inspection is focused on infection control procedures and practices of this facility.

The facility is a licensed continuing care retirement community, consisting of an assisted living building, which includes dementia care services area, current total resident count is sixty-three(63); There is also a skilled nursing building on the property which is monitored by Department of Health. Hospice care waiver approved for fifteen(15) residents. Facility has a dementia plan of operation approved by the Department. Mitigation plan submitted and reviewed by the Department. Fire clearance is approved for 152 nonambulatory, which includes 25 bedridden. The third (3rd) floor approved for non-ambulatory only.
LPA toured the facility with the Administrator Mariele, The LPA observed the front lobby entrance where the screening check in is conducted. The LPA was screened before being allowed to remain in the facility. There is a log book with screening questions, and the Concierge takes the individual's temperature and provides the reading to them. The screening is logged. LPA observed exits free from obstruction. The facility has approximately a 90 day supply of personal protective equipment (PPE), the LPA observed the PPE storage area. Residents have masks available to them for their use if needed and/or wanted. Administrator stated that all staff wear masks in the facility, including when providing care services to the residents in and out of the facility. Administrator had a mask on during the LPA's inspection, and all the staff the LPA observed during the inspection had masks on. LPA observed the stairwells, and the evacuation chairs were in place, including the instructions on their use in an emergency. Facility staff were observed to be preparing meals for the residents dinner service.The facility has sufficient supplies of food, and a sufficient supply of paper products, and cleaning/disinfecting products. Fire extinguishers were tagged and serviced on 3/1/2022 per the Administrator, and the Maintenance Director. LPA observed two fire extinguishers that had February 2021 tagged dates during today's inspection. The Administrator stated that the contracted Company that services the fire extinguishers will be contacted and a request for them to come out and reinspect the fire extinguishers for correct tags and/or correct dates, and if they serviced all fire extinguishers as this is why they contracted with the Company. The Administrator will provide the documentation showing that the fire extinguishers have been inspected and tagged as documented in the paperwork.
No deficiencies cited today. Exit interview conducted with Administrator Mariele Soriano.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
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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