496801635-7-20-2021-21-AS-HDBI-C5B3EN-20210726181121

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 07/20/2021
Date Signed: 07/20/2021 03:36:45 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
03/24/2021 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20210324144111

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:	07/20/2021
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Resident Services Director, Tru Coiner		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Neglect/Lack of Supervision - Lack of staffing to meet the care needs of residents

INVESTIGATION FINDINGS:

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Licensing Program Analysts Willis and Gonzalez Campos arrived unannounced to deliver findings regarding the above-mentioned complaint allegation and met with Resident Services Director, Tru Coiner.

Complaint alleges that private caregivers were providing tasks that should have been provided by the facility including but not limited to assistance with activities of daily living and notifying a resident's responsible party following a medical incident. Evidence provided indicated that resident, R1 received services from a personal care attendant approximately three to four hours per day. Review of documents shows that the hours were broken up with the care attendant coming in in the morning and in the evening. During the April 16, 2021 visit, LPA requested the most recent Needs and Services Plan for R1 and was provided a Needs and Services Plan that noted on March 3, 2020 that resident was to be provided “assistance with socks and shoes daily and as needed.” Multiple interviews revealed that the personal care attendant provided dressing in the morning and night. Investigation did not reveal additional information regarding who contacted the resident's responsible party following the medical incident.

Continued on LIC9099C

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: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

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

Control Number 21-AS-20210324144111

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
	VISIT DATE: 07/20/2021

NARRATIVE

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Continued from LIC9099

The allegation Neglect/Lack of Supervision - Lack of staffing to meet the care needs of residents is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210324144111

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: 07/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/21/2021 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	87464 Basic Services Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.	1 2 3 4 5 6 7	Facility agrees to update their Personal Care Attendant policy to clarify that Personal Care Attendants do not provide Basic Services by POC due date, 7/21/2021.
	8 9 10 11 12 13 14	Requirement was not met as evidenced by: Based on interviews and document review, Licensee did not ensure that facility was providing Basic Services related to dressing. This is an immediate risk to health and safety of residents in care.	8 9 10 11 12 13 14
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	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: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

LIC9099 (FAS) - (06/04)

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