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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 06/15/2021
Date Signed: 06/15/2021 12:45:42 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: 30DATE:
06/15/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Resident Services Director, Tru Coiner.TIME COMPLETED:
01:00 PM
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Licensing Program Analyst Willis arrived unannounced to conduct a Plan of Correction visit and met with Resident Services Director, Tru Coiner.

During a visit dated 6/10/2021 LPA observed that construction zone in the back of the facility is accessible to residents in care. The construction zone was deemed hazardous as the following items were accessible to residents: 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. During visit, LPA explained that the area needs to be secured immediately and a more secure fence needs to erected within 24 hours. Prior to LPA leaving, the temporary fence and caution tape was put back up and Administrator had reached out to construction company.

During today's visit, LPA toured the construction area and observed the following: There is not a fence around the construction area and the items listed above are still accessible to residents. Additionally, more lumber (with nails) and concrete debris and additional tools including an electric chainsaw (was not plugged in) were observed. The caution tape and cones cordoning off the area have been pushed down. LPA and RSD discussed the potential health and safety risks of not having a secured fence around that area with LPA indicating concern because approximately a week ago a resident in Memory Care left the locked unit and walked to the back of the facility. A caregiver was able to stay with the resident and direct them away from the construction area, per interview. LPA stated that the construction tools that have been left near the construction trailer must be locked up.

Administrator has received a quote from a company that would be putting up the fence but a date of when the fence would be up has not yet been determined. Additionally, Administrator has put up signs to direct residents away from the construction area. LPA indicated that additional measures would need to be taken to ensure resident safety until a fence could be secured.

Civil penalties are being assessed today in the amount of $400.00 for failure to correct deficiency and will continue to run at $100.00 per day until corrected.

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

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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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