Santa Rosa Fire Department (SRFD) attendees: Fire Marshall, Mike Johnson, and Assistant Fire Marshall, Kemplen Robbins.

Varenna attendees as follows: Page Ensor, CEO, Gallaher Signature Living, Douglas Blake, Executive Director/Administrator, Gallaher Signature Living, Jennifer Haney, L.V.N., Wellness Navigator, Gallaher Signature Living, and Lori Ferguson, Partner, Hanson Bridgett

This meeting is being conducted to discuss concerns identified by the Licensing Agency in recent complaint investigations, 21-AS-20260130125255 and 21-AS-20260223152740. The following are concerns that have been identified during the complaint investigations:

• Facility has not followed through with obtaining required updated medical assessment/medical visits for medical updates on all residents in care, ensuring reappraisals are completed for all residents, as required.
• Facility has not followed through with ensuring when residents are observed with any changes in physical health conditions, etc, observations are addressed appropriately, per regulations.
• .Facility’s third, 3^rd, floor is fire cleared, by the SRFD, for ambulatory only residents; The facility has residents that are non-ambulatory residing on the third floor, which is a violation of the fire clearance approval. This deficiency was cited, 3/30/26, which included an immediate civil penalty assessment.

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

87463(a)(h) Reappraisals- The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

87466 Observation of the Resident- The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

87202(a) Fire Clearance - All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal

87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

Plan of continued compliance with ensuring facility residents are residing in appropriately fire cleared units, medical assessments, and observations are addressed as required.

Facility to ensure care plans are documented from the reappraisals, ensuring care needs are being met, for all residents. Facility has provided information on 3^rd floor residents, and plan on obtaining needed medical assessments/medical updates and reappraisals on residents residing on the third floor.

Continued on LIC809C..

Facility agreed to the above items discussed and will ensure the facility’s plan of operation is in compliance with Title 22 regulations/HSC requirements, for RCFE/CCRC, at all times.

Facility will submit the plan of having a"fire watch" in place for the facility, each building, main building, North building, South building, and for the casitas on the property. The fire watch will remain in place, on each shift, until the 3rd floor is in compliance, and the Department has received the new STD850 fire clearance inspection approval. This "fire watch" plan is due to the Department by 4/29/26.

Licensing reviewed a recent resident incident that was reported by Varenna, which included a required SOC341, suspected abuse report; Varenna acknowledged the incident reported, and how the facility is addressing the concerns of suspected financial abuse of a resident, by a volunteer at Varenna. Varenna terminated the volunteer due to this incident and have told the former volunteer they are not allowed on-site and/or access to residents on-site, due to the suspected financial abuse.

Varenna has agreed to submit any documentation related to this incident, including follow-up documentation/information regarding the financial abuse of the resident by the facility’s former volunteer; Administrator will submit this documentation by 4/24/26.

No deficiencies cited during today's meeting.