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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108102
Report Date: 12/18/2024
Date Signed: 12/18/2024 03:01:35 PM

Document Has Been Signed on 12/18/2024 03:01 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VILLA MARIN AMBULATORY CARE UNITFACILITY NUMBER:
210108102
ADMINISTRATOR/
DIRECTOR:
DURANCZYK, PAULFACILITY TYPE:
741
ADDRESS:100 THORNDALE DRIVETELEPHONE:
(415) 499-8711
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 28CENSUS: 12DATE:
12/18/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Director of Nursing, Bridget Geist, and Administrator, Paul DurancyzkTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a 1-Year Required Visit and met with Director of Nursing, Bridget Geist, and Administrator, Paul Duranczyk. Facility is a Continuing Care Retirement Community (CCRC) and has a portion of the property licensed as a Residential Care Facility for the Elderly (RCFE). This portion of the property provides care and assistance for Older Adults in Assisted Living. Facility has an approved fire clearance and capacity for 28 Non-Ambulatory or Bedridden Residents. Facility has a Hospice Waiver for 5 individuals. Upon arrival, LPA was informed that there were currently 12 residents in care and 3 staff members on-site.

LPA reviewed the Facility's Staff Roster with Director of Nursing and found that all staff members on site were background cleared and associated to the facility per regulation. LPA reviewed staff and resident files, and resident medications. Staff files were found to be well organized, thorough and contained the required documentation. LPA reviewed a sample size of 5 resident files. During review, LPA observed Resident 1 and 2, (R1 and R2) did not have a negative TB test on file (deficiency cited, LIC809D, regulation 87458(b)(1)). Medication was centrally stored and secure. During medication review, LPA observed that the facility uses a written Medication Authorization Record (MAR) and a centrally stored log. LPA observed that some medications had incorrect medication expiration and fill dates, while other medications were correctly documented per regulation. LPA and Director of Nursing discussed reviewing centrally stored medication log and documentation expectations (see technical violation, LIC9102, regulation 87465(h)(6)). Administrator's Certificate for Paul Duranczyk (7010307740) was current with an expiration date of 10/26/2025.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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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Document Has Been Signed on 12/18/2024 03:01 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 12/18/2024 at 02:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VILLA MARIN AMBULATORY CARE UNIT

FACILITY NUMBER: 210108102

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensee did not comply with the section cited above. LPA observed that 2 of 5 resident files did not have a negative TB test on file. This poses a potential health and safety risk to residents in care.
POC Due Date: 12/28/2024
Plan of Correction
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Licensee to administer tb tests to identified residents, and submit proof of test results to Community Care Licensing (CCL) by POC Due Date of 12/28/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
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