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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 03/15/2021
Date Signed: 03/15/2021 05:03:30 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
03/10/2021 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20210310123256
FACILITY NAME:HEALDSBURG SENIOR LIVING COMMUNITYFACILITY NUMBER:
496801635
ADMINISTRATOR:MEASE, TRACEYFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: DATE:
03/15/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Resident Care Coordinator, Tru CoinerTIME COMPLETED:
05:12 PM
ALLEGATION(S):
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Facility did not respond to Family Council timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst Victoria Willis and Licensing Program Manager Hope DeBenedetti arrive unannounced regarding the above mentioned complaint allegation and met with Resident Care Coordinator, Tru Coiner. Administrator was unavailable during inspection.

Complaint alleges that the facility has not responded to a request for information from the Family Council. Per documentation provided, letter was sent to facility on February 22, 2021 and Administrator confirmed during visit that they have not responded to the Facility Council letter.
The allegation that Facility did not respond to Family Council timely 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.
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.

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: 03/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021
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 2
Control Number 21-AS-20210310123256
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: 03/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2021
Section Cited
HSC
1569.158(f)
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ยง1569.158 Family councils (f) If a family council submits written concerns or recommendations, the facility shall respond in writing regarding any action or inaction taken in response to the concerns or recommendations within 14 calendar days. This requirement has not been met based on documentation and conversation showing that
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Facility agrees to submit proof that they have responded to the Family Council's written concerns by POC due date, 3/17/2021.
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Licensee falied to respond to written concerns brought by the Family Council. This 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: 03/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021
LIC9099 (FAS) - (06/04)
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