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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 12/31/2020
Date Signed: 12/31/2020 10:52:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COMMUNITYFACILITY NUMBER:
496801635
ADMINISTRATOR:ROB MATTHEWSFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: DATE:
12/31/2020
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Acting Administrator Amanda North, Pacifica Senior Living representatives, Marlene Nelson and Jackie BobbittTIME COMPLETED:
09:45 AM
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Licensing Program Analyst Victoria Willis, Licensing Program Manager Bethany Moellers and Assistant Program Administrator Pam Gill met with Acting Administrator Amanda North and representatives from Pacifica Senior Living, Marlene Nelson and Jackie Bobbitt via teleconference to conduct an Informal Conference.

The following areas of concern were addressed:
  • Covid-19 Protocols including Infection Control and Personal Protective Equipment
  • Adequate Staffing
  • General Oversight

CCL has requested the following documents to be submitted:
  • LIC500 - Personnel Report
  • Proof of training for donning and doffing of PPE and Infection Control
  • Updated Mitigation Plan to include disinfecting of facility
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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