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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 06/03/2021
Date Signed: 06/03/2021 03:17:25 PM

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:MEASE, TRACEYFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 34DATE:
06/03/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Executive Director, Tracey Mease and Resident Service Director, Tru CoinerTIME COMPLETED:
03:17 PM
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Licensing Program Analysts Victoria Willis and Erik Gonzalez-Campos arrived unannounced to conduct a Case Management-Legal/Non-compliance Inspection and met with Executive Director, Tracey Mease and Resident Service Director, Tru Coiner.

Upon arrival, LPAs were screened by the receptionist and logged in. LPAs conducted a walk-through of facility to address compliance with the facility Mitigation Plan. Covid-19 posters were observed at the entrance to the main facility that houses Assisted Living. Posters were not observed in Memory Care. Per Resident Service Director, facility is not currently logging when staff disinfect facility nor are they doing a daily symptom checklist for residents. Staff are screened before they come on shift.

PPE was sufficient.

LPA provided the following guidance:
  • Regularly review Provider Information Notices to ensure facility is following the most current guidance, specifically PINS 21-17-ASC and 21-17.1-ASC regarding communal dining, visitation, ect.
  • Post Covid-19 Posters in Memory Care regarding cough etiquette and hand washing.
  • Review Facility Mitigation Plan to ensure it is being followed.

Additionally, LPA observed that the CCL Complaint Poster is not posted in Assisted Living. Facility was instructed to put poster up in the main entrance of Assisted Living.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
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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