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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 10/08/2020
Date Signed: 01/05/2021 11:33:31 AM

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:ROB MATTHEWSFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 44DATE:
10/08/2020
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:TIME COMPLETED:
03:00 PM
NARRATIVE
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Acting Regional Manager Carla Martinez, Licensing Program Manager Hope DeBenedetti, Licensing Program Analyst Victoria Willis and Long Term Care Ombudsmen Crista Nelson met with Licensee, Thomas Patke, Administrator, Rob Matthews, Resident Care Coordinator, Terry Kemp to conduct an Informal Meeting regarding areas of concern. Due to COVID concerns the meeting was conducted virtually. A Change of Ownership is pending for Pacifica Senior Living and representatives from the Applicant were also in attendance.

During the meeting the following items were discussed:

· Facility’s policy on observed changes of condition and seeking medical attention
· Facility’s policy on incident reporting including notifying the physician and responsible parties
· Facility’s policy on charting and documentation
· Staff and Resident Records
· Administrator Duties
· Covid-19 Protocol

Facility will be providing additional documents discussed during todays meeting by close of business on 10/10/2020.
Following the meeting, LPA Willis and LPM DeBenedetti conducted a subsequent call with Administrator Rob Matthews to go over the report memorializing the meeting.
A copy of PIN 20-38

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

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
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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