496801635-4-16-2021-21-AS-HDBI-C2P42W-20210503184347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 04/16/2021
Date Signed: 04/16/2021 04:48:30 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
02/08/2021 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20210208111715

FACILITY NAME:	HEALDSBURG SENIOR LIVING COMMUNITY		FACILITY NUMBER:	496801635
ADMINISTRATOR:	MEASE, TRACEY		FACILITY TYPE:	740
ADDRESS:	725 GROVE STREET		TELEPHONE:	(707) 433-4877
CITY:	HEALDSBURG	STATE: CA	ZIP CODE:	95448
CAPACITY:	82	CENSUS:	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Tru Coiner		TIME COMPLETED:	04:48 PM

ALLEGATION(S):

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Resident was not given medication as prescribed
Facility did not meet the care needs of the resident
Responsible party was not notified regarding resident's change of condition
Facility did not provide records upon request

INVESTIGATION FINDINGS:

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Licensing Program Analyst Willis arrived unnanounced to obtain deliver findings regarding the above-mentioned complaint allegations and met with Resident Care Coordinator, Tru Coiner.

During inspection LPA conducted interviews, obtained and reviewed staff and resident records and made observations.

Resident was not given medication as prescribed - Complaint alleges that resident, R1 was given a double dose of a medication explaining that it was discovered via a co-pay being charged. Review of the Medication Administration Record (MAR) did not document a double dose of medication nor was it noted in the resident's file. Additionally, complaint alleges that resident was not given medication at onset of symptoms as prescribed by their doctor. Review of the MAR confirms that the medication was not given however review of the file did not document an onset of symptoms.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210208111715

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: 04/16/2021

NARRATIVE

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Continued from LIC9099

Facility did not meet the care needs of the resident - Complaint alleges that R1 was transported to the hospital because they were found on the floor and had not eaten in multiple days. Review of the Emergency Report indicated that resident was sent to hospital for "shortness of breath and 'looking not right'" and does not mention whether resident was found on the floor prior to transport nor does it mention resident not eating. Complaint also alleges that after leaving the hospital, resident was observed with raw skin speculating that resident was left in soiled garments. Review of emergency room report from resident's intake into hospital did not note skin breakdown.

Responsible party was not notified regarding resident's change of condition - Complaint alleges that resident's responsible party was not notified that resident was transported to the hospital and instead the hospital notified them. LPA was unable to confirm through file review whether resident's responsible party was notified.

Facility did not provide records upon request - Complaint alleges that facility did not provide records for resident, as requested. Complainant was unable to provide proof that records were requested in writing per regulation and request was not observed during file review.

A finding that the complaint allegations that resident was not given medication as prescribed, facility did not meet the care needs of the resident, responsible party was not notified regarding resident's change of condition, and facility did not provide records upon request was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred. We have therefore dismissed the complaint.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

LIC9099 (FAS) - (06/04)

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