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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 08/02/2021
Date Signed: 08/02/2021 03:36:20 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:
08/02/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator, Tracey Mease and Resident Services Director, Tru CoinerTIME COMPLETED:
03:46 PM
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Licensing Program Analyst Willis arrived unannounced to conduct a Case Management inspection and met with Administrator, Tracey Mease and Resident Services Director, Tru Coiner.

LPA is following up regarding citations that were issued on July 20, 2021 and July 28, 2021. On July 20, 2021 LPA cited a deficiency that included multiple physical plant concerns. Facility submitted pictures that showed two out of three issues were remedied. The third issue, a hole in the ceiling in Memory Care is being repaired today, August 2, 2021, per Administrator. LPA observed that a vendor was on-site during visit. The location of the hole is in a room that can be made inaccessible to residents.

LPA also discussed the outstanding plan of correction regarding insufficient staffing that was cited July 28, 2021. Administrator told LPA that their plan is to ensure that there are two caregivers on shift at all times along with a Med Tech in Memory Care. The Med Tech will be available to provide care and supervision as needed, specifically during breaks and lunches. Administrator will submit the written plan to CCL by the end of the day.

Administrator also updated LPA regarding the phone system that has been replaced and is currently being programmed.

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

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
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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