496804113-2-24-2023-21-AS-DALO-CNW3ER-20230209171133

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804113
Report Date: 02/09/2023
Date Signed: 02/24/2023 02:53:45 PM

Document Has Been Signed on 02/24/2023 02:53 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:	FOUNTAINGROVE LODGE		FACILITY NUMBER:	496804113
ADMINISTRATOR:	MOONEY, SHAWN		FACILITY TYPE:	741
ADDRESS:	4210 THOMAS LAKE HARRIS DRIVE		TELEPHONE:	(707) 576-1101
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 173		CENSUS: 134	DATE:	02/09/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Shawn Mooney-Administrator		TIME COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LPA met with Shawn Mooney, Administrator, to amend the report to reflect the inspection type, pre-licensing. Licensing Program Analyst(LPA) Alviso conducted a pre-licensing inspection and met with the Administrator Shawn Mooney. This is a change of ownership application, the facility is currently operating, this inspection is unannounced. LPA will be touring the facility with the Administrator. The requested capacity remains at one hundred and seventy-three(173), The fire clearance approval dated 12/12/22, clears the facility for one hundred and fifty-seven(157) nonambulatory, and sixteen(16) bedridden, total capacity of 173. The new fire clearance approval document does not specify the required breakdown of the nonambulatory & bedridden clearance for each building (two of them), and the five bungalows; The delayed egress approval was not specified in the fire clearance as required. The LPA will request the application unit in Sacramento follow-up on this and obtain a fire clearance with specific clearance approval. LPA can provide the following information but it must be on the new fire clearance document to ensure it is valid/approved by Local Fire Department. Current fire clearance approval reads, main building, and the five bungalows are cleared for one hundred and forty(140) nonambulatory, which includes six(6) bedridden. The memory care building is cleared for thirty-three(33) nonambulatory which includes ten(10) bedridden- total license capacity is one hundred and seventy-three(173) . LPA does not see that the new applicant has any changes to the requested capacity from current status. A sample of fire extinguishers were checked and found to be serviced and tagged as required, expires 12/14/23, forty-two(42) in assisted living. All exits were unobstructed. Continued on LIC809C...

SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: FOUNTAINGROVE LODGE	FACILITY NUMBER: 496804113
	VISIT DATE: 02/09/2023

NARRATIVE

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There is a locked medication room on the first floor for centrally storing all medication. There are numerous locked rooms for storage of supplies, and locked storage rooms for toxins and/or cleaners. LPA observed a sufficient supply of food. LPA observed the facility has emergency supplies as required, including food and water. Sufficient supply of furnishings, lighting in hallways and restrooms. All resident units have non-slip mats/flooring in showers/baths, bathroom grab bars for resident use. All three stairwells in the AL building have the required evacuation chairs, with instructions. The facility also has an extra large electric evacuation chair if needed. Sufficient PPE supply.

LPA toured the memory care, a sample of fire extinguishers were checked and found to be serviced and tagged as required, expires 12/14/23, nine(9) in memory care. There was sufficient supply of furnishings. Medication room for centrally stored medication. Storage rooms for securing toxins and any items that may pose a risk to residents in care. There were grab bars and non slip surfaces/mats in restrooms. The memory care consists of 2 floors, there is an evacuation chair with instructions at the stairwell. Entrance leads into a large lounge lobby area and to a delayed egress door/locked perimeter-key pad entry- there are resident rooms, beauty shop, theater room, large activity room, large dining room and a private dining room. There is a large outside courtyard for residents' use. Sufficient PPE supply.

Administrator Shawn Mooney completed component III orientation.

LPA will forward a copy of the prelicensing inspection to the Application Unit Analyst; The Application Unit Analyst will contact the applicant with the status of the application.

SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC809 (FAS) - (06/04)

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