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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 07/28/2021
Date Signed: 07/28/2021 05:44:38 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:
07/28/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:49 PM
MET WITH:Resident Services Director, Tru CoinerTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst Willis arrived unannounced and met with Resident Services Director, Tru Coiner.

This report is intended to address areas of non-compliance that were discovered during a complaint inspection but is unrelated to the complaint. LPA obtained documents during investigation that indicates that the management company is using their plan of operation including marketing materials and general policies to operate the facility. The new plan of operation has not been submitted to LPA for approval.

Additionally, LPA observed that the CCL Complaint Poster is not posted in Assisted Living per regulation and has verbally requested for the poster to be put up but that has not yet happened.

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: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2021
Section Cited

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87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be
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submitted to the licensing agency for approval. Licensee has not met this requirement based on:.Per LPA interviews and document review, management company is using their plan of operation that has not been approved by LPA. This is a potential risk to the health and safety or residents in care.
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Type B
08/02/2021
Section Cited

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1569.33 Unannounced inspections; notification of deficiencies; compliance; reports (i) (1) The department shall design, or cause to be designed, a poster that contains information on the appropriate reporting agency in case of a complaint or emergency. (2) Each residential care facility for the elderly shall post this poster in the main entryway of its facility.
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Licensee has not met this requirement based on:.Per LPA observation, facility does not have a CCL Complaint Poster in the main entryway of the facility This is a potential risk to the health and safety or 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: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2