<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 09/18/2020
Date Signed: 11/04/2020 10:49:59 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/02/2020 and conducted by Evaluator Victoria Willis
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200302162434
FACILITY NAME:HEALDSBURG SENIOR LIVING COMMUNITYFACILITY NUMBER:
496801635
ADMINISTRATOR:ROB MATTHEWSFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 62DATE:
09/18/2020
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Rob MatthewsTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to seek timely medical attention for resident
Facility failed to notify authorized representative of an incident regarding a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**Amended

Licensing Program Analyst met with Acting Administrator, Marlene Nelson via televisit in order to deliver findings regarding the above mentioned complaint allegations.

During investigation, The Department conducted interviews with staff, medical professionals and other involved parties, made observations and reviewed documents. Based on multiple interviews and a review of various documents the Department learned that Resident, R1 had an unwitnessed fall on 02-24-2020, however, R1 was not sent to the hospital until 02-27-2020 at which time was diagnosed with a hip injury. According to interviews, staff noted at the time of the fall R1's knee was swollen and R1 complained of pain yet medical attention was not sought. Multiple interviews noted deformity in R1's leg on the days following the fall. Based on documentation and statements interviewed individuals, it was concluded that the resident fell on 2-24-2020, complained of pain daily, observed with deformity to the hip/leg and medical attention was not sought until 2-27-2020.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
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 5
Control Number 21-AS-20200302162434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: HEALDSBURG SENIOR LIVING COMMUNITY
FACILITY NUMBER: 496801635
VISIT DATE: 09/18/2020
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
**Amended

Continued from LIC9099

Incident report dated 2/27/2020, indicated that R1's responsible party was notified of their fall when resident was taken to the hospital. Staff was unable to provide documentation showing that R1's responsible party was notified at the time of the initial fall. Interview with R1's responsible party indicated that they did not receive notification from the facility at the time of the fall and was not notified of the fall until the resident was sent to the hospital three days later.

The Department has determined that the allegations that facility failed to seek timely medical attention for resident and the facility failed to notify authorized representative of an incident regarding a resident is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An immediate civil penalty is assessed today in the amount of $500 for a violation resulting in serious injury of a resident in care. Enhanced Civil Penalty is pending review per Health and Safety Code.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/02/2020 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20200302162434

FACILITY NAME:HEALDSBURG SENIOR LIVING COMMUNITYFACILITY NUMBER:
496801635
ADMINISTRATOR:ROB MATTHEWSFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 62DATE:
09/18/2020
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Rob MatthewsTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Insufficient care and supervision resulting in resident sustaining a fracture
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**Amended

Licensing Program Analyst met with Acting Administrator, Marlene Nelson via televisit in order to deliver findings regarding the above mentioned complaint allegations.

During investigation, The Department conducted interviews, made observation and reviewed documents. Statements made to The Department by staff were inconsistent as to whether resident, R1 was a one-person or two-person transfer anytime they needed to be moved from one location to another. The resident was provided a bed alarm that notified staff if the resident fell out of bed. Although this resident is noted as a fall risk, the facility management provided a bed alarm for the resident and the resident was checked every 20-30 minutes. Based on this information, it is unclear if the staff were negligent or failed to properly supervise the resident.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20200302162434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: HEALDSBURG SENIOR LIVING COMMUNITY
FACILITY NUMBER: 496801635
VISIT DATE: 09/18/2020
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
**Amended

Continued from LIC9099A

A finding that the complaint allegations of Insufficient care and supervision resulting in resident sustaining a fracture was unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegations occurred. We have therefore dismissed the complaint.

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20200302162434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: HEALDSBURG SENIOR LIVING COMMUNITY
FACILITY NUMBER: 496801635
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/19/2020
Section Cited
CCR
87466
1
2
3
4
5
6
7
87466 Observation of the Resident. Licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning & appropriate assistance is provided when such observation reveals unmet needs. When changes such as...deterioration of mental ability or a physical health condition are observed, Licensee shall
1
2
3
4
5
6
7
Administrator agrees to submit planned training dates for all staff regarding observation of a residents to CCL by POC due date...

Additionally, Administrator will provide company protocol outlining how residents are observed for changes and how those changes are reported to management.
8
9
10
11
12
13
14
ensure that such changes are documented & brought to the attention of the resident's physician & the resident's responsible person, if any. Requirement is not met as evidenced by: Based on interviews it was determined that staff observed a change of condition in 1 of 1 resident (R1) but didn't notify R1s physician which poses an immdiate health and safety risk to residents.
8
9
10
11
12
13
14
**An immediate civil penalty is assessed today in the amount of $500 for a violation resulting in serious injury of a resident in care. Enhanced Civil Penalty is pending review per Health and Safety Code.
Type B
11/11/2020
Section Cited
CCR
87466
1
2
3
4
5
6
7
*Amended 87466 Observation of the Resident-Licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning & that appropriate assistance is provided when such observation reveals unmet needs. When changes such as... physical health condition are observed, the licensee shall ensure that
1
2
3
4
5
6
7
Facility agrees to submit self certification that designated staff has read, understand and will follow regulation and the facility policy surrounding observing changes in residents and notifying their responsible party by POC due date, 11/11/2020.
8
9
10
11
12
13
14
such changes are documented & brought to the attention of the resident's physician & the resident's responsible person, if any. Requirement wasn't met based on interviews indicating that R1's responsible party wasn't notified of R1's fall until three days later. This is a potential risk to health and safety of residents in care.
8
9
10
11
12
13
14
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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5