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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 06/10/2021
Date Signed: 06/10/2021 12:52:24 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:
06/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Executive Director, Tracey Mease and Resident Service Director, Tru Coiner.TIME COMPLETED:
01:07 PM
NARRATIVE
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Licensing Program Analyst Willis arrived unannounced to continue investigation regarding the above-mentioned complaint allegations and met with Executive Director, Tracey Mease and Resident Services Director, Tru Coiner.

During investigation, LPA made observations unrelated to the complaint investigation. Facility is currently building a separate building on the campus. During a Pre-Licensing inspection on 4/28/2021, LPA Willis and LPM Nuti-Martinez observed the construction zone and requested that the area be made inaccessible. Subsequent conversations with Administrator, Tracey Mease indicated that caution tape and plastic fencing was put up adding that residents with cognitive decline were in a locked area of the campus.

During today's visit, LPA observed that the plastic fence was no longer upright and accessible construction materials were observed including but not limited to: boards with nails jutting out, rebar on the ground and coming out of the ground, containers with motor oil and various tools including framing nails and a shovel. Per Administrator, the fence was pushed down when the construction company delivered lumber. LPA explained that the area needs to be secured immediately and a more secure fence needs to erected within 24 hours. The fence must be strong enough and tall enough to ensure residents are unable to gain access to the hazardous area. Prior to LPA leaving, the temporary fence and caution tape was put back up and Administrator had reached out to construction company.

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.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2021
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on observation, Licensee did not
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ensure that hazardous materials were made inaccessible to residents in care. This is an immediate risk to 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: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2021
LIC809 (FAS) - (06/04)
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