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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 03/05/2021
Date Signed: 03/05/2021 03:30:08 PM



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
12/18/2020 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20201218161720
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:
03/05/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Tracey Mease and Resident Care Coordinator, Tru CoinerTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility has insufficient staffing to meet the residents’ needs
Facility staff failed to provide adequate food service
Facility staff is not trained
Facility staff failed to meet the resident's needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Willis met with Administrator, Tracey Mease and Resident Care Coordinator, Tru Coiner via Televisit to deliver findings regarding the above complaint allegations. Visit was completed via tele-visit to observe Covid-19 precautions.

During investigation LPA interviewed staff, residents and various outside parties, including but not limited to responsible parties, medical providers and long term care ombudsman, conducted virtual tours of the facility on 12/10/20, 1/4/21, 1/6/21, 1/14/21, 1/25/21 and 2/11/21 and reviewed various documents such as resident, staff and facility records, communication records, medical records and pictures.

Facility has insufficient staffing to meet the residents’ needs - Based on interviews and LPA observations during various virtual tours at the facility LPA learned that facility had experienced insufficient staffing/staffing shortages in Memory Care partially due to a recent outbreak of Covid-19 which resulted in delays in residents receiving assistance with activities of daily living including but not limited to toileting, showering and meals.
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: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
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 4
Control Number 21-AS-20201218161720
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: 03/05/2021
NARRATIVE
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Continued from LIC9099C

Staffing issues during the same time-frame are addressed in complaint dated 1/5/2021.

Facility staff failed to provide adequate food service - Complaint alleges that resident is not provided with assistance with meals. Based on a review of resident records and medical records, a tour of the facility and multiple Interviews. LPA learned that due to recent Covid-19 outbreak, meals are provided to residents in their rooms except for residents in Memory Care. Interviews and a tour of the facility identified that each room in Assisted Living has a microwave for heating food items. Facility staff stated that staff will heat food for resident if needed or if a resident asks for it to be heated but multiple interviews indicated that food was served cold and residents were expected to heat the food themselves despite some residents being unable to operate the microwave. Additional staff interview identified that at least one of twenty-eight residents in Assisted Living requires prompting for eating adding that the identified resident, R1 has lost weight and was prescribed a nutritional drink from their doctor. Per staff interview, staff will check in to prompt R1 to eat but do not provide assistance/encouragement through out the entire meal and care staff are not directed to monitor and document if resident is drinking the nutritional drink.

Facility staff is not trained - Complaint alleges that facility staff are not trained on how to dispense medications. Based on interviews and a reviewed facility and staff records LPA verified that thirteen of thirteen staff records reviewed lacked sufficient training per regulation.

Facility staff failed to meet the resident's needs - The Complaint alleges that resident is not being assisted with showers and getting dressed. Review of resident's care plan identifies that assistance is needed with dressing and undressing. Multiple Interviews conducted during investigation identified instances of missed and delayed shower days, staff refusing to assist with transferring and delays in assistance with activities of daily living.

The allegations that facility has insufficient staffing to meet the residents’ needs, facility staff failed to provide adequate food service, facility staff is not trained and facility staff failed to meet the resident's needs are Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20201218161720
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: 03/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2021
Section Cited
CCR
87555(b)(9)
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87555 General Food Service Requirement The following food service requirements shall apply: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by: Based on multiple interviews, licensee did not ensure food quality and
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Administrator agrees to submit facility protocol outlining how residents who need additional help with heating meals and prompting with eating will receive those services per POC due date, 3/6/2021.
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accessibility by food not being served at the correct temperature and residents not being assisted with meals which poses an immediate risk to health and safety of residents in care.
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Type A
03/06/2021
Section Cited
CCR
87464(f)(1)
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87464 Basic Services Basic services shall at a minimum include: (1) Care & supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on multiple interviews, the licensee did not ensure that all residents received assistance with activities of daily
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Administrator agrees to submit planned training for all care staff to ensure that basic services are being provided timely and per regulation. Training schedule to include Activities of Daily Living is due by POC due date 3/6/21. Proof of training for all care staff must be provided to CCL no later than 3/19/2021.
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living as needed which posed an immediate risk to health and safety.
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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: 03/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20201218161720
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: 03/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2021
Section Cited
HSC
1569.625(b)
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1569.625 Staff training; legislative findings; contents (b) The department shall adopt regulations to require staff members of RCFEs who assist residents with personal activities of daily living to receive appropriate training. This requirement is not met as evidenced by: Based on review of training records, the licensee did not ensure that all care staff
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Administrator agrees to submit proof that all staff providing care are trained per regulation/Health and Safety Code by POC due date 3/19/21.

New staff training shall consist of 40 hrs and 20 hrs of Annual Training for existing staff with details noted in H&S Code 1569.625.
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were trained per regulation which is a potential risk to the health and safety of residents in care.
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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: 03/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4