496801635-6-3-2021-21-AS-HDBI-C3V27Q-20210610170906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 06/03/2021
Date Signed: 06/03/2021 03:22:29 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
02/16/2021 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20210216143535

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: 34	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Executive Director, Tracey Mease and Resident Service Director, Tru Coiner.		TIME COMPLETED:	03:36 PM

ALLEGATION(S):

1
2
3
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5
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7
8
9

Facility did not reimburse responsible party timely

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
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12
13

Substantiated

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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

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
02/16/2021 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20210216143535

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: 34	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Executive Director, Tracey Mease and Resident Service Director, Tru Coiner		TIME COMPLETED:	03:36 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to ensure health and safety of resident in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts Victoria Willis and Erik Gonzalez-Campos arrived unananounced to deliver findings regarding the above complaint allegation and met with Executive Director, Tracey Mease and Resident Service Director, Tru Coiner.

Facility failed to ensure health and safety of resident in care – Complaint alleges that resident, R1 was not properly buckled into their seatbelt on a facility bus in 2019 resulting in resident falling and requiring immediate medical assistance. LPA reviewed hospital records and facility notes and conducted interviews. An incident report was not available for review. Facility staff knowledgeable regarding the incident no longer work at the facility so LPA was unable to obtain information from them.

A finding that the complaint allegation that facility failed to ensure health and safety of resident in care 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.

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: 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.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20210216143535

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: 06/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/04/2021 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	§1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually	1 2 3 4 5 6 7	Facility has since reimbursed responsible party. Deficiency is cleared.
	8 9 10 11 12 13 14	responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. Licensee did not meet the requirement as evidenced by documents and interviews indicating that facilty did not reimburse deceased resident's responsible party within 15 days.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3