496801635-7-28-2021-21-AS-HDBI-C5M3XT-20210805183853

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 07/28/2021
Date Signed: 07/28/2021 06:01:10 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
05/06/2021 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20210506092335

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:	07/28/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Resident Service Director, Tru Coiner.		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Facility is not maintaining records

INVESTIGATION FINDINGS:

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Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegation and met with Resident Service Director, Tru Coiner.

During investigation, LPA conducted interviews and reviewed documents. Complaint alleges that a resident had a change in medication that was not documented by the facility. Review of the Centrally Stored Medication log and doctor's orders revealed that there was a medication change in November of 2019 but there was not an order in the resident's file that reflected this.
The allegation that facility is not maintaining records 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.

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: 07/28/2021

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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

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
05/06/2021 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20210506092335

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:	DATE:	07/28/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Resident Service Director, Tru Coiner.		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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9

Resident not being assisted with self-administration of medication
Facility is failing to follow the current rate/fee schedule provided to residents and responsible parties

INVESTIGATION FINDINGS:

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Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegations and met with Resident Service Director, Tru Coiner.

During investigation, LPA conducted interviews and reviewed documents. Complaint alleges that facility staff left medication in a resident's room instead of staying and ensuring that the resident took the medication. Interviews with Medication Technician's denied leaving medication in resident rooms. Complaint alleges that facility charged for a service that they were not providing. Further interview revealed that the item was removed from the billing. LPA investigation revealed that the management company is utilizaing their fee schedule and Plan of Operation instead of the Plan of Operation of the existing Licensee. This is addressed in another report.
Finding that the complaint allegations, resident not being assisted with self-administration of medication
and that facility is failing to follow the current rate/fee schedule provided to residents and responsible parties was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred. We have therefore dismissed the complaint.

No deficiencies cited.

Unsubstantiated

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: 07/28/2021

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.

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 21-AS-20210506092335

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: 07/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/11/2021 Section Cited CCR 87405	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications	1 2 3 4 5 6 7	Facility agrees to review facility policy regarding medication changes with all medication technicians and document training. Documented training to be submitted to CCL by POC due date, 8/11/2021.
	8 9 10 11 12 13 14	as needed. Licensee did not meet this requirement based on: LPA review of file indicates that the physician's order for the resident's change in medication was not maintained in the file. This is a potential risk to the health ans safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

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