Varenna at Fountaingrove

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Resident's pendant alarm is not responded to in a timely manner

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 8/4/26, and met with Administrator, Brooke Patterson, and Executive Director, Derrick Defino. RP alleges that "resident's pendant alarm is not responded to in a timely manner". LPA reviewed resident, R1's, records. LPA reviewed facility records. LPA conducted interviews with staff, and other related parties regarding alleged allegation. Per record reviews of pendant alarm systems log, from April 2026 and July 2026, following information was obtained. R1's calls for assistance/care needs, the log showed some specific dates of the pendant alarm response times, by staff, documented as follows: On 4/3=14 mins, 4/12= 14 mins, 4/16=13 mins, 4/17=15 mins, 4/21= 14 mins, 4/22= announced 7 times but received no staff response, 4/29= announced 7 times but received no staff response, 7/12= 14 mins, 7/17=16 mins, and 7/22=17 mins. Continued on LIC9099C.. Substantiated The investigation revealed that R1 had some pendant calls for assistance, with their ADLs, that were not answered timely, and two (2) calls for assistance with ADLs that were not responded to by facility staff. Per LPA interviews with administration staff, the direct care staff, including medication -technicians, are trained to respond to resident pendant alarms right away, in a timely manner, at all times. There is sufficient information obtained to support a violation occurred regarding "resident's pendant alarm is not responded to in a timely manner". Deficiencies will be cited as follows: 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities-To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs, see LIC9099D. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with Administrator Douglas Blake. Report provided, including appeal rights. Record review of, Facility Policy regarding personal care attendants revealed, "Personal Care Attendants- Residents who desire to use a personal care attendant for extended periods of time may do so with prior approval of the Administrator." Procedure #2 of this Policy states, " Personal Care Attendants from outside agencies may be used if approved by the Administrator. The agency shall ensure a criminal clearance on all staff, health screening, appropriate insurance including liability and workers compensation, proof of appropriate employer tax obligations, including but not limited to withholding of state and federal taxes, payment of disability and unemployment insurance. All appropriate labor laws are to be followed and the personal care attendant supervised by an agency administrator familiar with this assisted living community operations". Information obtained from resident's (R1's) contract regarding "Private Caregivers and Companions" in section 4.11, and from facility's policy regarding "Personal Care Attendants", did not support that a violation had occurred regarding the alleged allegation "staff did not allow resident to contract private care services". Based on the investigation, the allegation is Unfounded. We have found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited. Exit interview was conducted with Administrator Brooke Patterson, and Executive Director Derrick Defino. Report provided to Administrator.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 21-AS-20260505223848

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 21, 2026

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities-To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs, The investigation revealed that R1 had some pendant calls for assistance, with their ADLs, that were not answered timely, and two (2) calls for assistance with ADLs, that were not responded to by facility staff. This is a risk to residents personal rights.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Licensee/Administrator to ensure that all residents pendant alarm calls are responded to in a timely manner, and responded to at all times. Ensure the pendant alarms system is in working order for resident R1's unit, ensuring all resident's care needs are being met, as required by care plan, and current needs. Submit plan of future compliance, and staff training with caregivers and all staff that respond to resident's pendant alarms. Training regarding the pendant alarm policyand procedures as well as this regulation requirement. POC due by 8/21/26.

Allegation investigated: Staff did not allow resident to contract private care services

Licensing Program Analyst (LPA) Alviso conducted a complaint visit, on 8/4/26, and met with Brooke Patterson, Administrator, and Derrick Defino,Executive Director. Reporting party alleges "staff did not allow resident to contract private care services". LPA reviewed resident (R1) records, including their admission agreement/contract. The LPA requested copies of resident records, and the Administration staff provided the copies to the LPA. LPA reviewed facility records, and obtained requested copies. LPA conducted interviews with staff, and other related parties regarding the alleged allegation. The investigation revealed that per R1's contract, Section 4.10, Private Caregivers and Companions- In the event you require private duty care for a short term illness or injury, you must first make this request known to Varenna management. Continued on LIC9099.... Unfounded If Varenna is unable to provide the necessary private duty personnel, then you may hire a private caregiver or companion if they: (1) first register with Varenna and provide proof of licensure and liability insurance; and (2) comply with all of Varenna's policies and procedures for private caregivers and companions. Registration with Varenna is not an endorsement of the private caregivers or companions by Varenna. You shall select such personnel in your discretion and pay for their services. Record review of, Facility Policy regarding personal care attendants revealed, "Personal Care Attendants- Residents who desire to use a personal care attendant for extended periods of time may do so with prior approval of the Administrator." Procedure #2 of this Policy states, " Personal Care Attendants from outside agencies may be used if approved by the Administrator. The agency shall ensure a criminal clearance on all staff, health screening, appropriate insurance including liability and workers compensation, proof of appropriate employer tax obligations, including but not limited to withholding of state and federal taxes, payment of disability and unemployment insurance. All appropriate labor laws are to be followed and the personal care attendant supervised by an agency administrator familiar with this assisted living community operations". Information obtained from resident's (R1's) contract regarding "Private Caregivers and Companions" in section 4.10, and from facility's policy regarding "Personal Care Attendants", did not support that a violation had occurred regarding the alleged allegation "staff did not allow resident to contract private care services". Based on the investigation, the allegation is Unfounded. We have found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited. Exit interview was conducted with Administrator Brooke Patterson, and Executive Director Derrick Defino. Report provided to Administrator.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 21-AS-20260130125255

Allegation investigated: Staff did not reappraise resident (s) in care Staff did not regularly observe residents for changes in their condition Staff did not provide assistance to resident in care in a timely manner

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 6/15/26 at approximately 12:45pm, and met with Administrator Douglas Blake. RP alleges that "staff did not reappraise resident (s) in care”, “staff did not regularly observe residents for changes in their condition”, and "staff did not provide assistance to resident in a imely manner. LPA reviewed resident, R1 and R2, records. LPA obtained copies of specific records reviewed. LPA reviewed documents provided by other related parties. LPA conducted interviews with staff, and other related parties regarding alleged allegations. The investigation revealed that residents, R1 and R2, were not regularly reappraised as needed per observations/changes in residents’ health condition, physical condition, etc. Residents, R1 and R2, did not have annual reappraisals as required, to ensure that residents’ current needs, if any, would be met as required. This would include obtaining updated medical information on the residents as needed, to ensure an appropriate re-assessment is completed. Continued on LIC9099C.. Substantiated R1 moved into the facility in 2008, per record reviews, there is a medical assessment dated 9/24/2008, marked as ambulatory and independent. There is another medical assessment dated 8/24/21, marked as ambulatory but showing some activities of daily living items stating, “please assess” and “supervision assistance”. R1 is marked as not being able to handle own medications/medication equipment, having anxiety, and dysphasia. No re-assessment is on file, after this medical report of 8/24/21. Per interviews and reviewed incidents, R1 had some incidents of observed confusion, including observed behaviors that were noticed as a change in resident's baseline/health condition. Appraisal/Reappraisals found in record review, independent upon move in, in 2008, a reappraisal plan dated 5/31/23, which has resident, being provided shower/bathing once a week. A reappraisal dated 11/21/25, no changes, showers once a week, and resident’s (R1) needs will be met by staff; Resident R1 has a private duty companion per record reviews. Per record reviews, R2 had a medical assessment dated 11/7/2008, appraisal shows R2 as independent. In 2011 there was an appraisal marking R2 as independent and handling own medications. Medical assessment dated 11/14/25. R2 was receiving some care assistance from staff due to their terminal illness. R2 was assessed for hospice care services; Hospice care plan is dated 10/30/25. R2 handled own medications and medical equipment until they were no longer able to self-manage their medications. R2 had some fall incidents, and R2 was assessed as needed by staff and emergency personnel. R2 was admitted into skilled nursing care, and was on comfort care until their passing, on 11/15/25. Per record reviews of pendant alarm systems log, regarding R1's calls for assistance/care needs, the log showed many dates from 1/21/26 through 4/15/26 where the pendant alarm received no response as required, which is documented numerous times in the alarm systems log. There were alarm calls noted as being responded to 15 minutes or later, per review of report log. Per interviews with other related parties, staff would arrive 30 minutes after the alarm call and/or sometimes never arrive to provide care needed to R1. Staff could not provide proof that the alarm calls listed as not having been responded to, were responded to by staff as required. Continued on LIC9099C... Per investigation, it is identified that reappraisals, were not obtained on residents annually and/or as needed per incidents and/or observed changes in resident (s) and/or changes in health conditions, ensuring to obtain updated medical information as needed. Per record reviews and interviews, R1 was identified as having a neurocognitive disorder, which may have been the result of the observed changes in R1, regarding incidents. Ensuring a follow-up of updated medical information, including reassessment/care plan as needed. LPA was provided the call alarm pendant log for R1's pendant; It is identified per pendant alarm systems log that some of R1's pendant calls were not answered timely and, some alarm calls were listed as not having been responded to at all, per log. Facility staff were not able to provide proof of the alarm calls having been responded to that were listed as not having a response. Per Administrator the unit has a malfunction regarding the pendant being reset. There is sufficient information obtained to support the violations occurred regarding the allegations. Deficiencies will be cited as follows: 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, see LIC9099D. 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 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, see LIC9099D. 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities-To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs, see LIC9099D. The preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with Administrator Douglas Blake. I1 has a criminal record clearance, per review of guardian, database of DOJ fingerprint clearances. R1 had a lunch they attended with a friend at the Villa Capri facility, which is a sister facility of Varenna, and is right below the Varenna facility. R1 had agreed to a lunch at Villa Capri willingly, and does have a right to say yes or no to luching with a friend. Per iterviews, and record reviews, there was no transfer of residence of R1 to another facility, R1 is residing in Varenna. There is no obtained information to support violations occurred. The allegations are found to be unsubstantiated. Based on the interviews, and related information obtained during the investigation, the allegations are Unsubstantiated, meaning that although the allegation (s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur. No deficiencies cited. Exit interview was conducted with the Administrator Douglas Blake.the state’s words, verbatim · CDSS document, Jun 15, 2026 · control 21-AS-20260130125255

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a)(h) · Plan of correction due date: Jul 10, 2026

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, This requirement was not met as evidenced by: Per review of records and interviews, residents, R1 and R2 did not receive regular annual assessments and reappraisals as required, per regulations/HSC. R1 had two medical assessments on record, 2008 and 2021. R1 had a reappraisal 2008, 2023, and 2025. R2 had medical assessment in 2008, and 2025, an appraisal in 2008, and hospice care 2025. Residents did not get reappraised as required by regulations. This is a health & safety and/or a personal rights risk to residents.the state’s words, verbatim · CDSS document, Jun 15, 2026

Plan of correction: Licensee/Administrator to ensure that all residents obtain reappraisals as required, ensuring that residents all receive current care needs as required. Submit plan of future compliance with this regulation requirement by 7/10/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jul 10, 2026

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 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, This requirement was not met as evidenced by: Per investigation, it is identified that resident was not reappraised when observations in their cognitive status and behavior were observed by staff,rper incidents and interviews with staff. R1 was identified as having a neurocognitive disorder, which may have been why resident was observed with health condition changes.This is a personal rights risk and/or health & safety risk to residents.the state’s words, verbatim · CDSS document, Jun 15, 2026

Plan of correction: Licensee/Administrator to ensure that all residents observed changes in condition, per regulations, are addressed in a timely manner, and residents current needs are being provided. Obtain medical updates as needed, and reappraise resident , ensuring an updated care plan is in place. Submit plan of future compliance with this regulation requirement by 7/10/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4 · Plan of correction due date: Jul 10, 2026

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities-To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement was not met as evidenced by: LPA was provided the call alarm pendant log for R1's pendant; It is identified per pendant alarm systems log that some of R1's pendant calls were not answered timely and, some alarm calls were listed as not having been responded to at all, per log. Facility staff were not able to provide proof of the alarm calls having been responded to that were listed as not having a response. This is a risk to residents personal rights and/or to health & safety of residents.the state’s words, verbatim · CDSS document, Jun 15, 2026

Plan of correction: Licensee/Administrator to ensure that all residents pendant alarm calls are responded to in a timely manner, and at all times. Ensure the pendant alarms system is in working order for resident's unit, ensuring all resident's care needs are being met. as required. Submit plan of future compliance with this regulation requirement by 7/10/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Alviso, conducted a Required- 1 Year inspection, on 5/14/26 at approximately 9:45am, and met with Administrator Douglas Blake. LPA toured the facility with Norma Rudolph, Housekeeping Supervisor, and Lawrence Whitlow, Regional Director of Maintenance. LPA reviewed a recently received a resident (R1) incident report, and SOC341, suspected abuse report. LPA requested records regarding the incident, and records on how the resident incident was addressed, including facility's investigation into the reported incident. The Administrator agreed to submit the copies to the LPA no later than 5/20/26. 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 and do not have 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. There are three buildings, the main "Villetta" building, the North building, the South building, and twenty-seven (27) Casitas on the property. Recent fire inspection of 4/7/2026. Nonambulatory first two (2) stories only. The fire clearance is approved for, 72 ambulatory, 250 non-ambulatory, and 8 bedridden; Total capacity is three hundred twenty-two, 322. Capacity breakdown- Villetta building(1st & 2nd FL)-132 non-ambulatory, includes 8 bedridden, third floor of Villeta building 72 ambulatory only, Casitas #1 through #27, 54 non-ambulatory, and North & South buildings, 64 non-ambulatory. Continued on LIC809C.... LPA observed the residents, total of five (5) assessed as non-ambulatory on the 3rd floor, have all vacated the units; Four (4) of the five (5) have moved to other available non-ambulatory units within the building, and one (1) resident chose to move out of Varenna. The third floor as of 5/5/26 is back in compliance with facility's fire clearance approval. Regarding the implemented fire watch plan, required by Licensing/CCL, a re-inspection fire clearance was completed, fire clearance was approved on 4/7/26, as stated on the first page of this report. Due to the above, and 3rd floor back in fire clearance approval status, the "fire watch plan" may end as of today, 5/14/26. The annual will continue at a later date. No deficiencies cited during today's inspection. Exit interview conducted with Administrator/ED Douglas Blake.the state’s words, verbatim · CDSS document, May 14, 2026

Type of visit: Office

An informal office meeting was held today with Varenna at Fountaingrove, Gallaher Senior Living Management LLC, 4/22/26, in the Santa Rosa Regional Office. Present in the meeting were the following licensing staff: Regional Manager, Carla Martinez, Licensing Program Manager, Bethany Moellers, and Licensing Program Analyst, Dina Alviso. 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, 3rd, 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. Continued on LIC809C... Regulation requirements shown below on the noted items of concern. 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 3rd floor residents, and plan on obtaining needed medical assessments/medical updates and reappraisals on residents residing on the third floor. Continued on LIC809C.. The plan on ensuring all residents residing on the 3rd floor are ambulatory only. Facility to keep licensing updated on compliance for ensuring “ambulatory only” are residing on the 3rd floor. Ensuring the facility is in compliance with the fire clearance approval at all times; Fire clearance is approved for three hundred and twenty-two (322) as follows: Villetta building(1st & 2nd FL)-132 non-ambulatory, includes 8 bedridden, third floor of Villeta building 72 ambulatory only, Casitas #1 through #27, 54 non-ambulatory, and North & South buildings, 64 non-ambulatory. 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.the state’s words, verbatim · CDSS document, Apr 22, 2026

Allegation investigated: Staff are inappropriately making resident move apartments Staff did not give resident's authorized representative a 30-day notice to move apartments

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 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... 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.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 21-AS-20260223152740

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) conducted a case management visit, on 3/30.2026 at approximately 3:32pm, and met with Administrator Douglas Blake. This case management is addressing deficiencies identified by the LPA during a complaint investigation conducted earlier today, 3/30/26. There is no exception or waiver to the fire clearance approval, and the facility is to maintain compliance with the fire clearance.Per record reviews, R1 had a medical assessment on 2/22/23 that identified a change in condition; R1 was marked as non-ambulatory, per physical condition, and was residing on the 3rd floor which is fire cleared for "ambulatory only". This is a deficiency, and will be cited, 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, see LIC809D. An immediate civil penalty will be assessed in the amount of $500, see LIC421IM. Continued on LIC809C.. R1 did not have an appropriate reappraisal as required by change of condition, and after the after the medical assessment completed on 2/22/23. There was not a plan addressing resident's non-ambulatory status and move to an appropriately fire cleared unit, per a reappraisal meeting new needs of R1. This is a deficiency, and will be cited, 87463(a)(b) 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 reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident, see LIC809D. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited, Failure to correct deficiency(s) by due date(s), may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with Administrator Douglas Blake. Appeal Rights provided to the Administrator with report.the state’s words, verbatim · CDSS document, Mar 30, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Mar 31, 2026

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. This requirement was not met as evidenced by: R1 had a medical assessment on 2/22/23 that identified a change in condition; R1 was marked as non-ambulatory, per physical condition, and was residing on the 3rd floor which is fire cleared for "ambulatory only". R1 remained residing on the 3rd floor until just recently, R1 was moved into an appropritely fire cleared unit 2/2026 This is a risk to residents health & safety.Immediate CP assessed $500.the state’s words, verbatim · CDSS document, Mar 30, 2026

Plan of correction: Licensee/Administrator to submit plan of correction ensuring future compliance with fire clearance approval, ensuring the 3rd floor has ambulatory only residents, per fire clearance. Submit how the facilityi is working to ensure compliance of facility's 3rd floor occupancy concerns. This needs to be completed in a timely manner, include sufficient staffing and plan of action until all nonambulatory residents are moved/transferred off the 3rd floor. Continue to keep Licensing agency updated. POC due 3/31/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a)(b) · Plan of correction due date: Apr 6, 2026

87463(a)(b) Reappraisals- The 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. The reappraisal shall document significant changes in the redent's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented. R1 did not have an appropriate reappraisal as required by change of condition after the medical assessment completed on 2/22/23. There was not a plan addressing resident's non- ambulatory status and move to an appropriately fire cleared unit, per a reappraisal meeting new needs of R1. This is a risk to residents personal rigthts and health & safety.the state’s words, verbatim · CDSS document, Mar 30, 2026

Plan of correction: Licensee/Administrator to ensure that all residents have annual medical assessments and reappraisals annually and/or as often as needed. Ensure any/all residents on 3rd floor, which is fire cleared for ambulatrory only have needed medical assessments & reappraisals, ensuring current needs are addressed and met by the facility.Submit plan of action in ensuring compliance with the above. POC due 4/6/26.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) conducted a case management visit, on 3/25/26 at approximately 1:20pm, and met with Administrator Douglas Blake. LPA requested documents from specific resident files The Administrator provided all requested documents to the LPA during the inspection. There are no deficiencies cited today.the state’s words, verbatim · CDSS document, Mar 25, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alviso conducted a case management inspection, on 1/5/26 at approximately 9:30am, and met with Interim Administrator, Donald Rodreick. LPA met with Health & Wellness Director/LVN, Heidi Gallagher. Case management is being conducted to obtain information on a resident incident reported by the facility. LPA reviewed resident R1's records; LPA reviewed the facility file on R1's private companion. LPA obtained the facility's policy regarding private companions for residents'. Administrator provided copies to the LPA during the inspection. There were no deficiencies cited during today's inspection. Exit interview conducted with Interim Administrator, Donald Roderick.the state’s words, verbatim · CDSS document, Jan 5, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA), Alviso, conducted a continued annual inspection, on 05/13/25 at approximately 2:00pm, and met with Administrator Assistant Don Rodreick. Annual inspection was started on 4/14/2025, see LIC809. 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. The fire clearance is approved for three hundred and twenty-two (322) as follows: Villetta building(1st & 2nd FL)-132 non-ambulatory, includes 8 bedridden, third floor of Villeta building 72 ambulatory only, Casitas #1 through #27, 54 non-ambulatory, and North & South buildings, 64 non-ambulatory. Hospice waiver granted for five (5) residents. The facility does not have a dementia plan of operation. The facility does have a required "Infection Control Plan." The facility does have an "Emergency Disaster Plan" as required. Per record reviews, emergency disaster drills were conducted as required; Last emergency drills were an evacuation drill on 2/26/25, and a fire drill on 3/17/25. The LPA reviewed eight (8) staff files, including all required training, LPA reviewed medication training for staff that assist residents' with medications. Direct care staff had first aid and CPR as required by their position. All staff have criminal record clearance as required. There were no deficiencies cited during today's inspection. Exit interview conducted with Administrator Assistant, Don Rodreick.the state’s words, verbatim · CDSS document, May 13, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA), Alviso, conducted a continued annual inspection, on 04/24/25 at approximately 1:45pm, and met with Administrator Ferdinand Buot, and Administrator Assistant Don Rodreick. Annual inspection started on 4/14/2025, see report LIC809. 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. The fire clearance is approved for three hundred and twenty-two (322) as follows: Villetta building(1st & 2nd FL)-132 non-ambulatory, includes 8 bedridden, third floor of Villeta building 72 ambulatory only, Casitas #1 through #27, 54 non-ambulatory, and North & South buildings, 64 non-ambulatory. Hospice waiver granted for five (5) residents. The facility does not have a dementia plan of operation. The facility does have a required "Infection Control Plan." The facility does have an "Emergency Disaster Plan" as required. This plan is kept up in a cabinet behind the concierge desk. There is a concierge staff to the right as you enter the facility. LPA reviewed ten (10) resident files. Resident files were complete. LPA starting reviewing staff files, and staff required training. The LPA will return to complete a review of all staff required caregiver training, medication training, and emergency disaster training. The LPA will review records on required emergency disaster drills. The LPA will continue the annual inspection at a later date. No deficiencies cited during today's inspection. Exit interview conducted with Administrator Assistant Don Rodreick.the state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Alviso, conducted a Required- 1 Year inspection, on 04/14/25 at approximately 12:45pm, and met with Administrator Assistant Don Rodreick. 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. The fire clearance is approved for Villetta building(1st & 2nd FL)-132 non-ambulatory, includes 8 bedridden, third floor of Villeta building 72 ambulatory only, Casitas #1 through #27, 54 non-ambulatory, and North & South buildings, 64 non-ambulatory. LPAs checked random fire extinguishers, and they were marked and having been serviced and tagged as required. Hospice waiver granted for five (5) residents.The facility does not have a dementia plan of operation. The facility does have a required "Infection Control Plan." The facility does have an "Emergency Disaster Plan" as required. This plan is kept up in a cabinet behind the concierge desk. There is a concierge staff to the right as you enter the facility. LPAs observed the emergency lock box with master keys to all rooms, and facility vehicles, accessible to staff as needed in an emergency. The North building and South building, both each have a lock box with master keys for staff use as needed in an emergency. Emergency supplies are stored in both the main building, North building, and South building for use in an emergency. All first aid kits had required first aid guide/booklet. Continued on LIC809C... LPAs toured the facility with Norma Rudolph, Housekeeping Supervisor, Bonafacio Carmona Maintenance Director, and Gustavo Manriquez. All exits in the main building, North building, and South building were observed by the LPA to be clear of obstruction. The main building has five (5) stairwells, and all had the required evacuation chairs. The North building has two (2) stairwells, and the South building has two (2) stairwells, all four (4) stairwells had required evacuation chairs, and instructions posted up. All three garage generators were checked and were working properly during the inspection. The facility had food, water, and supplies to meet the "72 hour shelter in place" requirements. Food supply was sufficient. Cleaners/disinfectants were locked and inaccessible as required. Hot water was measured at 110.3 degrees, and 117.5 degrees Fahrenheit in the main building. Hot water in the North building was measured at 116.6 degrees Fahrenheit LPA is requesting the following documents be updated and submitted by 5/14/25. LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required) Infection Control Plan (ensure to review and update as needed/required) Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed by all licensees. Copy of current Administrator Certificate Copy of current Liability Insurance. The LPA will continue the annual inspection at a later date. No deficiencies cited today. Exit interview conducted with Administrator Assistant, Don Rodreick.the state’s words, verbatim · CDSS document, Apr 14, 2025

Allegation investigated: Facility staff are not safeguarding residents personal property and personal space

Licensing Program Analyst (LPA) Alviso conducted a complaint visit, on 3/13/25 at approximately 9:20am, and met with Executive Director/Administrator Ferdinand Buot, and Administrator Assistant Don Rodreick. Reporting party alleges that the facility staff are not safeguarding residents personal property and personal space. LPA reviewed resident (R1) records, including incident reports and admission agreement. LPA reviewed facility records, including facility's policy and procedures regarding theft & loss, safeguarding residents personal property. The LPA requested copies of records; Administrator provided copies to the LPA during the inspection. The LPA reviewed records, conducted interviews with staff, and other related parties. The investigation revealed that R1 had reported a missing bracelet; The Police Officer that came out to the facility to do an investigation report was permitted by R1 to conduct a search in resident's unit; The Police Officer found R1's bracelet, R1 confirmed it was the bracelet that had been report missing. The LPA's investigation found that some of the cooking spices had been brought in by R1's visitors they had over in the recent past. Continued on LIC9099C.. Unsubstantiated The investigation found no information obtained on clothing being put in R1's closet that doesn't belong to R1. There was no information obtained regarding over-the-counter (OTC) medications being put into R1's unit. LPA interviews relayed that the over-the-counter medications found by R1 in the unit had been discarded. There was no information obtained regarding if anyone is coming into R1's unit throwing away OTC medications/supplements, bringing clothing into R1's closet, No information was obtained in the investigation to support a violation (s) had occurred regarding the allegation (s). Based on the interviews, and related information obtained during the investigation, the allegation (s) of "facility staff are not safeguarding residents personal property and personal space" is Unsubstantiated, meaning that although the allegation (s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur. No deficiencies cited. Exit interview was conducted with the Administrator Ferdinand Buot.the state’s words, verbatim · CDSS document, Mar 13, 2025 · control 21-AS-20250307080406

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alviso conducted a case management inspection, on 3/13/25 at approximately 9:20am, and met with Executive Director/Administrator Ferdinand Buot, and Administrator Assistant Don Rodreick. Case management is being conducted to obtain information on a resident incident reported by the facility. LPA reviewed resident (R1) records, including incident reports and admission agreement. LPA reviewed facility records, including facility's policy and procedures regarding theft & loss, safeguarding residents personal property. The LPA requested copies of records; Administrator provided copies to the LPA during the inspection. LPA interviewed staff, and other related parties regarding the incident. There were no deficiencies cited during today's inspection. Exit interview conducted with the Administrator Ferdinand Buot.the state’s words, verbatim · CDSS document, Mar 13, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs), Alviso and Loera, conducted an annual inspection, on 7/31/24 at approximately 1:10pm, and met with Administrator/Executive Director Ferdinand Buot. The fire clearance is approved for Villetta building(1st & 2nd FL)-132 non-ambulatory, includes 8 bedridden, third floor of Villeta building 72 ambulatory only, Casitas #1 through #27, 54 non-ambulatory, and North & South buildings, 64 non-ambulatory. LPA checked random fire extinguishers which were serviced and tagged as required. Per file review, an evacuation drill was held on 6/26/24; Various emergency drills, and fire drills are being conducted as required. LPAs reviewed six (6) resident files; Files were complete. LPAs reviewed six (6) staff files. Staff had criminal record clearance as required. Staff had required annual training. There are no deficiencies cited during today's inspection. Exit interview conducted with the Administrator Ferdinand Buot.the state’s words, verbatim · CDSS document, Jul 31, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Alviso, conducted a Required- 1 Year inspection, on 5/23/24 at approximately 10:15am, and met with Administrator/Executive Director Ferdinand Buot, and Administrator Assistant Don Rodreick. The LPA observed the front lobby entrance has hand sanitizer available for use by all residents, visitors, and staff. There is a concierge staff to the right as you enter the facility;There is a sign in/sign out log at the concierge desk. The fire clearance is approved for Villetta building(1st & 2nd FL)-132 non-ambulatory, includes 8 bedridden, third floor of Villeta building 72 ambulatory only, Casitas #1 through #27, 54 non-ambulatory, and North & South buildings, 64 non-ambulatory. LPA checked random fire extinguishers, and they were marked and having been serviced and tagged-expires 4/9/25. Hospice waiver granted for five (5) residents. The facility does have an "Emergency Disaster Plan" as required. This plan is kept up in a cabinet behind the concierge desk. Emergency keys to all rooms, and facility vehicles, is kept in lock boxes hanging in the copy room, which is the room behind the concierge desk. The facility does have a required "Infection Control Plan." The facility does not have a dementia plan of operation. 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. LPA toured the facility with Norma Rudolph, Housekeeping Supervisor, and Josh Borodic, Maintenance Director. All exits in the main building, North building, and South building were observed by the LPA to be clear of obstruction. The facility has hand sanitizer available for use in all facility buildings, they are put out in different areas throughout the facility. Continued on LIC809C... LPA observed all emergency disaster supplies, main building has three (3) storage areas on the 1st floor, two (2) storage areas on the 2nd floor, and two (2) storage areas on the 3rd floor. The main building has five (5) stairwells, and all had the required evacuation chair. All evacuation chairs had instructions posted up as required. The facility had food, water, and supplies to meet the "72 hour shelter in place" requirements. The kitchen had a sufficient supply of food, perishable and non-perishable. There was a sufficient supply of cleaners, paper products, and hygiene products. All housekeeping carts the LPA observed throughout the facility were locked, making all cleaners/toxins inaccessible to others/residents. The South building has three (3) emergency disaster supply bins, one (1) stored on each floor. The two stairwells had the required evacuation chair. All evacuation chairs had instructions posted up as required. The North building has two (2) supply bins, one stored on each floor. The two stairwells have the required evacuation chair. All evacuation chairs had instructions posted up as required. North and South buildings both have key storage lock boxes with emergency access keys to units in each building. North and South Casitas each have one large bin of emergency supplies stored at each site. All medications were stored in compliance with State and Federal requirements. There is a refrigerator in the medication room, for any medications needing to be stored refrigerated. All medication logs were up-to-date and had all required information. Narcotics were double locked, and are counted every shift change, documentation was shown to the LPA. LPA observed the beauty salon to be locked, ensuring toxins are not accessible to others/residents in care. All outside courtyards were clean, orderly, and had lots of outside furnishings, and shaded areas for resident use. All pathways, walkways, and entry/exit areas were free and clear of obstruction. LPA is requesting the following documents be updated and submitted by 6/23/24. LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required) Infection Control Plan (ensure to review and update as needed/required) Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed by all licensees. Copy of current Administrator Certificate No deficiencies cited today. The LPA will continue the annual inspection at a later date.the state’s words, verbatim · CDSS document, May 23, 2024