496803049-3-30-2026-21-AS-BMOS-DTDVB7-20260422161703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803049
Report Date: 03/30/2026
Date Signed: 03/30/2026 05:13:27 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/23/2026 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20260223152740

FACILITY NAME:	VARENNA AT FOUNTAINGROVE		FACILITY NUMBER:	496803049
ADMINISTRATOR:	BLAKE, DOUGLAS		FACILITY TYPE:	741
ADDRESS:	1401 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 526-1226
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	322	CENSUS: 227	DATE:	03/30/2026
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Douglas Blake-Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are inappropriately making resident move apartments

Staff did not give resident's authorized representative a 30-day notice to move apartments

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 3/30/266 at approximately 9:20am, and met with Administrator Douglas Blake.

Reporting party alleges "staff are inappropriately making resident move apartments" and "staff did not give resident's authorized representative a 30-day notice to move apartments".

LPA reviewed resident (R1) records, including admission documents, medical documentation, medical assessments, and medication records. LPA reviewed facility records, including emails, correspondence, and contact documentation with resident/responsible parties. LPA requested copies of specific records, which were provided to the LPA by the Administrator. LPA conducted interviews with staff, and other related parties.

The investigation revealed that per review of R1's records, medical assessment dated 2/19/26, identified resident as non-ambulatory, which this id the definition listed in the assessment "the prospective resident is unable to leave a building unassisted under emergency conditions.
Continued on LIC9099C....

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 21-AS-20260223152740

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: VARENNA AT FOUNTAINGROVE	FACILITY NUMBER: 496803049
	VISIT DATE: 03/30/2026

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
26
27
28
29
30
31
32

This includes, but is not limited to, a prospective resident/resident who depends upon mechanical aids such as crutches, walkers, and wheelchairs. It also includes a prospective resident /resident who is unable, or likely to be unable, to respond physically or mentally to a sensory signal approved by the State Fire Marshal, or an oral instruction relating to fire or other dangers, and if unassisted, to take appropriate action relating to such danger". Medical assessment identified that R1 uses a four wheeled walker, has motor impairment/paralysis, and requires assistance with repositioning and transferring with stand-by-assistance. R1's living unit was located on the third (3rd) floor which is fire cleared for ambulatory residents only by the Fire Department. Varenna's fire clearance approval is, "VILLETTA BLDG-132 NON-AMB, INCLUDES 8 BEDRIDDEN. THIRD FL 72 AMB. CASIITAS #1 THRU #27, 54 NON-AMB. NO & SO BLDGS-64 NON-AMB."

Per investigation, it was revealed that Upon R1's reappraisal on 2/18/26, by LVN Jennifer Haney, it was found that R1 was non-ambulatory per medical information obtained and reassessment On 2/19/26, LVN Jennifer Haney and RN Kari Miller contacted R1's responsible party to discuss the reappraisal of R1, and the non-ambulatory status. Responsible party was made aware of the third 3rd floor fire clearance of ambulatory only. Licensee/Administrator did not provide a 30-day written notice to R1 on moving apartments;

Administrator had contact with R1's responsible party/family regarding the resident's change in condition, fire clearance approval of the facility's 3rd floor, and R1's discharge back to the facility to a non-ambulatory unit, etc. Administrator had contact on several dates by phone/texts, letter correspondence, emails, and in person, per the following:
2/20 Phone Conversation Re: Discharge and Ambulatory Status
2/20 EM with Copy of License; with additional phone follow up
2/22 Apartment showing at 2Pm scheduled for responsible party
2/23 Care Conference held in person 11am
2/23 EM follow up to Care Conference
2/24 EM with Residency Agreement; EM with Addendum, Phone call at 920am & 350pm
2/24 Texts with questions; in person meeting to “touch base”
2/25 EM with care pricing; EM with notice of care conference; texts to coordinate in person meeting at 12pm; Texts re: Move on 2/26; phone call at 550pm
2/26 In person check ins through the day
2/28 Text to check in
Continued on LIC9099C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20260223152740

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: VARENNA AT FOUNTAINGROVE	FACILITY NUMBER: 496803049
	VISIT DATE: 03/30/2026

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
26
27
28
29
30
31
32

3/2 Text Re: Apt vacated
3/3 In person meeting at 12pm
3/5 EM regarding lighting
3/17 Test re: meeting on 3/18
3/18 In person meeting at 1030am regarding Apt & internal waitlist

Licensee did not issue 30-day notices to transfer units to an appropriately fire cleared room due to resident's change in condition. If a unit is available the resident may choose to transfer to the unit if agreed upon by all parties. Licensee does provide 30-day written notice of eviction when applicable, but Licensee/Administrator had not issued a 30-day notice of eviction at that time. The Administrator was offering the only available non-ambulatory unit for R1's transfer, covering cost of move into the unit, and some additional agreed upon items regarding the contract, the move, and the unit's amenities. R1 did return from the hospital and into the appropriately fire cleared unit, meeting their needs.

Regarding allegations of "staff are inappropriately making resident move apartments" and "staff did not give resident's authorized representative a 30-day notice to move apartments", there was information to support violations had occurred. The information obtained in this investigation didn't support that violations had occurred regarding alleged allegations.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations are UNFOUNDED. We have found that the complaint allegation(s) are/were unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies cited during today’s visit.
Exit interview was conducted with Administrator Douglas Blake.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 3