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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803049
Report Date: 04/28/2022
Date Signed: 04/29/2022 09:25:25 AM

Document Has Been Signed on 04/29/2022 09:25 AM - 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: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: 234DATE:
04/28/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ferdinand Buot-AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst(LPA) Alviso, and Department Management K. Gaines, conducted a continued 1 Year inspection, and met with Administrator Assistant Debbie Smith, and Dan Ferrarese, Maintenance Director. The inspection is focused on the Infection Control procedures and practices of this facility, and review of staff records, hiring documents, vaccination information, including staff training.

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, no provided assisted living care needs, at this time. If independent residents need care services at any time, these services may be added per the admission agreement, and the facility's plan of operation. Facility was toured with Dan Ferrarese, Main building , and both the South and North buildings. The facility has a large supply of personal protective equipment (PPE). The LPA observed the front lobby entrance where the screening check is conducted; There is a thermometer video scanner, hand sanitizer for use, and the Concierge will ask the screening questions and log the information as required. LPA was screened before being allowed to remain in the facility. LPA observed during the inspection, the Administrator and all other staff all wearing masks as required. Fire extinguishers were serviced and tagged as required- dated 4/18/21. The fire clearance is approved for Villetta building-132 non-ambulatory, includes 8 bedridden. Third floor 72 ambulatory, Casitas #1 thru #27, 54 non-ambulatory, and NO & SO buildings-64 non-ambulatory. Hospice granted for five (5) residents. LPA observed the food supply, perishable and non-perishable, to be sufficient during the inspection. The facility has a sufficient supply of food and water for the 72 hour shelter in place supplies. The facility has 14 large bins that contain required emergency supplies, and these are stored as follows: Main building has seven (7) bins on different floors, The South building has three (3) bins, one on each floor, and the North building has two(2) bins, one on each floor, and South and North Casita's each have one bin for each Casita area.
Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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Document Has Been Signed on 04/29/2022 09:25 AM - It Cannot Be Edited


Created By: Dina Alviso On 04/28/2022 at 03:24 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: VARENNA AT FOUNTAINGROVE
FACILITY NUMBER: 496803049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in the South building where there was rug installation going on; There were tools, rug scraps and other items left out in the hallways and in a sheeted area in a walkway making it a safety hazard for residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Licensee will hold an in-service training with Maintenance staff and ensure they are making sure all tools, and items that may pose a risk will be supervised when out and/or locked up to make them inaccessible to residents in care. Ensure that the hallways are free and clear from any debris and/or tools leaving enough room for residents to ambulate safely. Submit proof of training no later than 5/4/22. Plan of correction due by 4/29/22.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and Department staff, the licensee did not comply with the section cited above in there were two housekkeeping carts that were found unlocked with no housekeeper in-sight, the toxins/cleaners were unlocked and accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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The Licensee will hold an in-service with houskeeping staff to ensure that all housekeeping cleaning carts are locked as required ensuring the toxins are not left accessible to residents in care. Submit proof of training by 5/4/22. Proof of correction due by 4/29/22.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


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: VARENNA AT FOUNTAINGROVE
FACILITY NUMBER: 496803049
VISIT DATE: 04/28/2022
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The South building was having carpet installed and workers tools were left out in hallways on two floors, along with scraps of material and garbage from the work being done, this creates a safety hazard for residents using these hallways and entries into the building. This will be cited, see LIC809D.

The LPA and Department Managemnt staff observed two housekeeping carts that were left unsupervised by the housekeepers, leaving all toxins/claners accessible to residents in care. This will be cited, see LIC809D.

California Code of Regulations, (Title 22, Division 6, Chapter 8) and/or Health & Safety Code, is being cited on the following 809D.

Exit interview conducted with Administrator Debbie Smith. Appeal Rights given to the Administrator D. Smith.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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