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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 03:23:39 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
10/01/2020 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20201001083315
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 failed to have a designated staff responsible and accountable for the management and administration of the facility
Facility failed to notify responsible party of resident's change of condition
Facility failed to meet the care needs of the resident
Facility failed to seek medical attention in a timely manner
Facility failed to respond to resident's call for assistance in a timely manner
Facility failed to provide a copy of resident's file to the resident's authorized representatives upon request
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 failed to have a designated staff responsible and accountable for the management and administration of the facility - Complaint alleges that there is not designated staff to perform management duties after hours.

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 7
Control Number 21-AS-20201001083315
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 LIC9099

Based on interviews with facility staff LPA learned that it is facility policy to have phones routed to Skilled Nursing after hours and on the weekends and then a representative of Skilled Nursing transfers the call accordingly. Protocol is for Skilled Nursing staff to transfer the call and if there is no answer, they are to physically go over to the other unit and find a staff to take the call. When there is no manager available, the Medication Technicians are "in-charge". Interviews revealed that some family members have had difficulty getting a hold of a person in charge after hours commenting that there is really no way to get a hold of a manager or a point person on the weekends or after hours. Review of staff training revealed that five of seven Med-Techs reviewed did not have the training required to be a designated substitute for the Administrator.

Facility failed to notify responsible party of resident's change of condition – Complaint alleges that following the medical emergency, the facility did not notify the family that the resident was transported to the hospital. Facility was unable to provide proof that resident's family was notified of the change of condition.

Facility failed to meet the care needs of the resident - Complaint alleges that resident was not assisted with their hygiene needs. Multiple Interviews revealed instances where residents had delays in assistance with activities of daily living such as toileting and showering with some stating that personal care aides hired by the families and family members are providing care.

Facility failed to seek medical attention in a timely manner - Complaint alleges that resident R1 had two situations where the facility did not seek medical attention timely. One where the resident, R1 exhibited a change of condition and was not sent out until the family insisted and a second incident where R1 was exhibiting a medical emergency while on the phone with their family and attempts to reach the facility were delayed due to the phones being routed to Skilled Nursing. In the course of the investigation interviewees reported instances where facility did not seek medical attention timely including an incident where another resident, R2 was exhibiting pain and discoloration in their foot but was not sent to the hospital until 3 days later where, per interview, they were diagnosed with a broken ankle. A report from another responsible party stated that an item fell on resident, R3 in the presence of staff and medical attention was not sought despite resident complaining of pain. Interviewee

Continued on LIC9099C
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 7
Control Number 21-AS-20201001083315
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

recalled an incident where the responsible party observed resident, R4 with un-trimmed toenails that were described by the responsible party as purple. Resident, R5 had wounds which interviewee described as showing signs of not being cleaned.

Facility failed to respond to resident's call for assistance in a timely manner - Complaint alleges long delays between when the residents request assistance and when staff arrive in at least one case staff had started assisting a resident, was called away and did not return for approximately 45 minutes. Based on Interviews with facility staff and observations made during a virtual tour, LPA learned that the Assisted Living portion of the facility has a signal device in each hallway and the medication room which alerts staff that a resident needs assistance. Interviews with staff revealed that the facility does not track response times and there is not a mechanism for assigned care staff to alert another caregiver if they are unable to assist a resident timely and need help. Multiple Interviews indicated that residents have had delays in receiving assistance with activities of daily living in a timely manner and pull cords are not always in a place that is accessible to the residents. Some interviews identified lack of sufficient staffing as the reason staff were unable to respond to residents timely.

Facility failed to provide a copy of resident's file to the resident's authorized representatives upon request - Complaint alleges that the facility failed to provide a copy of R1's records to their authorized representatives upon request. Based on interviews and a review of documents LPA learned that responsible parties requested “progress notes and health care notes" and were provided resident's Physician's Report (LIC602) only. Despite further requests for all medical records, records were not provided by the facility, per interview. Facility was unable to provide documentation showing that they had provided records to the responsible party

The allegations that facility failed to have a designated staff responsible and accountable for the management and administration of the facility, facility failed to notify responsible party of resident's change of condition and facility failed to meet the care needs of the resident, facility failed to seek medical attention in a timely manner. facility failed to respond to resident's call for assistance in a timely manner and facility failed to provide a copy of resident's file to the resident's authorized representatives upon request 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.

*Civil Penalty Assessed for $1000.00 for repeating the same violation within 12 months.
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: 3 of 7
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
10/01/2020 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20201001083315

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 failed to maintain confidentiality of resident's records
Facility failed to treat the resident with dignity and respect
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 failed to maintain confidentiality of resident's records - Complaint alleges that the facility failed to maintain confidentiality of resident's records when the residents paperwork with confidential information was inadvertently provided to someone other than that 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: 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: 4 of 7
Control Number 21-AS-20201001083315
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 LIC9099

Based on interviews LPA learned that when the error was brought to the attention of the facility, the facility requested that the paperwork be destroyed, which it was. LPA was unable to prove or disprove that the records were ever provided to the wrong individual.

Facility failed to treat the resident with dignity and respect - Complaint alleges that the facility failed to treat residents with dignity and respect when speaking to residents. Based on multiple interviews LPA learned that the majority of interviewees indicated that staff treated residents with dignity and respect. LPA was unable to gather sufficient evidence to prove or disprove that residents were not treated with dignity and respect.

A finding that the complaint allegations that Facility failed to maintain confidentiality of resident's records and that Facility failed to treat the resident with dignity and respect 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: 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: 5 of 7
Control Number 21-AS-20201001083315
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
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 and responding to call buttons timely 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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Type A
03/06/2021
Section Cited
CCR
87466
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87466 Observation of Resident. Licensee shall ensure that residents are regularly observed for changes in physical...functioning & that...assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of... physical health condition are observed, licensee shall ensure
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Administrator agrees to submit facility protocol outlining how residents are observed for changes, how those changes are documented and communicated to resident's responsible party and doctor and who determines that a resident should receive medical intervention by POC due date 3/6/21.
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that such changes are documented & brought to the attention of the resident's physician & responsible person, if any. Requirement isn't met as evidenced by: Based on interviews, licensee didn't ensure that medical was sought for some residents who exhibited a need for it which posed an immediate risk to health & safety.
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Civil Penalty Assessed for $1000.00 for repeating the same violation within 12 months.
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: 6 of 7
Control Number 21-AS-20201001083315
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
03/12/2021
Section Cited
CCR
87506(c)(1)
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87506 Resident Records All information and records obtained from or regarding residents shall be confidential...The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not as evidenced by: Based on interviews
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Administrator agrees that all Management will read and submit self-certification that they have read and understand Regulation 87506 and submit self-certification to CCL by POC due date 3/12/21.
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and document review, the licensee did not ensure that records were provided to the resident or their designated representative upon written request which is a potential risk to the Health and Safety of residents.
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Type B
03/19/2021
Section Cited
CCR
87405(a)
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87405 Administrator - Qualifications and Duties ...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. This requirement was not as met as
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Administrator agrees to submit proof of training showing that all staff who are deemed "in-charge" in the absence of the Administrator, are trained per regulation 87405 by POC due date, 3/19/2021.
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evidenced by: Based on interviews and record review, the licensee did not ensure that five of seven Med-Techs reviewed have the training required to be a designated substitute for the Administrator which is a potential risk to the Health and Safety of residents.
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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: 7 of 7