496801635-8-17-2021-21-AS-VWIS-C5YUWU-20210817155719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 08/17/2021
Date Signed: 08/17/2021 03:57:41 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 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:	08/17/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Tracey Mease		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts Willis and Gonzalez-Campos, arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Tracey Mease. Upon arrival, LPAs observed that the front door was locked. It was later explained by the Resident Services Director, Tru Coiner that the front door is locked so the facility can ensure that all individuals who come to the facility are screened. LPAs were asked to screen themselves upon entry by a staff. LPAs initiated a tour of the facility around 9:10 am and made the following observations: Facility has a main building that consists of Assisted Living and a Skilled Nursing Facility. Two outbuildings house Memory Care residents but one is currently vacant. The Memory Care unit and Assisted Living was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in four of five resident rooms tested within regulation with the exception of one resident room in the Memory Care unit which read at 121.8 degrees F which is not within allowable range of 105 to 120 degrees F. Bathrooms had required bath mats and grab bars. While in the memory care unit, LPA observed a letter opener with a sharp point accessible to residents in care. Staff immediately removed the letter opener. While conducting a walk through of Assisted Living, LPAs observed kitchen and bathroom cleaner in the general laundry room and under the sink in a resident's room. Both cleaners were accessible to residents in care. During inspection of the kitchen, LPAs observed two containers of juice in the refrigerator that had expired. Kitchen staff immediately removed containers. Other food observed in kitchen appeared to be of good quality and was being stored per regulation. Eight out of nine fire extinguishers were last inspected March, 2021 with the exception of one located in the laundry room in the Memory Care unit. Administrator provided LPA with the most recent fire inspection done by their vendor dated 2/12/2020. Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

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 4

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
	VISIT DATE: 08/17/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC809

Per Administrator, due to the current fire system issue the fire system was tested last week. Based on interviews, the vacant Memory Care unit was previously identified as not meeting the fire departments' requirement and facility currently has a pending fire clearance due to this issue. This issue has caused delay in the change of ownership that was initiated in 2018. Exit doors for the Memory Care unit are alarmed and are delayed egress. Door alarms were functional during inspection.

LPA discussed the facility Emergency Disaster Plan with Administrator. LPA review of the plan indicates that the facility's two temporary shelter locations are the Veteran's Building located in Santa Rosa and a local high school that has previously been used as an evacuation site. LPA discussed the possibility of "sister" sites being used as temporary shelters considering the two listed may not always be designated evacuation centers. Per Administrator, Pacifica has other facilities that can be used in case of an evacuation. LPA also asked Administrator where keys are located and Administrator indicated that they have a key to the facility van and another set is located in the skilled nursing facility. LPA questioned whether staff are trained on the Evacuation Plan and whether the facility conducts quarterly drills. Administrator indicated that they do not have documented training for staff regarding the Emergency Disaster Plan and that they conducted a drill last quarter but have not this quarter. LPA requested documentation of the drill.

LPAs were unable to complete the Annual Inspection and will return to complete. Some deficiencies documented during this inspection will be addressed during the Annual Continuation.

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: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: 08/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as evidenced by two containers of juice being expired which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2021
	Plan of Correction
1 2 3 4	Facility staff immediately removed expired items. Deficiency is cleared.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one instance of a letter opener being accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2021
	Plan of Correction
1 2 3 4	Facility agrees to submit proof that staff have been in-serviced on regulation 87705 by POC due date, 8/18/2021.

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: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 08/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews, the licensee did not comply with the section cited above by having a significant delay in complying with the fire department's requirement which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2021
	Plan of Correction
1 2 3 4	Facility agrees to submit an update indicating how the current fire clearance will be remedied by POC due date, 8/18/2021. Due to fire concerns, facility must actively attempt to remedy the fire clearance issue no later than August 31, 2021.

Type A

Section Cited

CCR

87405(d)

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on evidence obtained during multiple inspections, the licensee did not comply with the section cited above in non-compliance including but not limited to staffing, training and resident care and supervision which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2021
	Plan of Correction
1 2 3 4	Administrator agrees to review regulation 87405 and submit self certification indicating that they have read and understand the regulation by POC due date, 8/18/2021.

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: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4