Varenna at Fountaingrove

Maintain fire clearance before retaining specified persons

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.

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.

Food handling safeguards during storage and service

Based on LPA's observation while touring the dining and kitchen areas with the Administrator, the facility did not ensure that pizza toppings, including pizza sauce, a variety of vegetables, and salad bar food items were stored appropriately to protect the safety and acceptability necessary to prevent contamination, which poses an immediate health, safety and/or personal rights risk to persons in care. LPA obtained photos for the file.

Maintain facility in clean, safe, sanitary condition

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.

Ensure hazardous items are locked and not unattended

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.

Dignity in personal relationships

87468.1(a)(1) Personal Rights of Residents in All Facilities-To be accorded dignity in their personal relationships with staff, residents, and other persons. Based on LPA's investigation, review of records and interviews, Staff 1 stated that staff 2 was sent to deliver two letters at separate times on 10/2/20, to R1's responsible party; The letters contained resident(s) confidential information. The first letter delivered was folded in half and not in a sealed envelope, and the second letter delivered later that same day was in a sealed envelope. The letter delivered folded in half was not ensuring residents right to confidentiality, as it left the contents in the letter accessible to be read/seen by others. This is a potential risk of personal rights of a resident(s) in care.