496801635-8-18-2021-21-AS-VWIS-C6227E-20210818170837

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 08/18/2021
Date Signed: 08/18/2021 05:08:50 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: 36	DATE:	08/18/2021
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Administrator, Tracey Mease		TIME COMPLETED:	05:20 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 Continuation Inspection and met with Administrator, Tracey Mease. Upon arrival, LPAs were let into the building by a staff member who screened LPAs and requested their vaccination records which LPAs provided. LPAs initiated inspection around 9:10 am. LPAs have returned to facility to continue the Annual Inspection that was initiated on August 17, 2021. During this inspection, LPAs reviewed resident and staff files, conducted interviews, and made observations. Resident file review revealed that five of twelve residents did not have Admission Agreements in their files. Facility staff indicated that the agreements may have been removed when thinning out the file and are actively looking for them. One of twelve residents did not have a Medical Assessment in their file. LPA reviewed eight staff files. Four of eight staff reviewed did not have a health assessment which included the results of a TB test. Additionally, one of eight staff did not have a fingerprint clearance. LPA observed staff in the facility this morning. Administrator indicated that the staff has left for the day and will not be returning until they have a fingerprint clearance. Staff was hired April 2021. A Civil Penalty is being assessed in the amount of $500 for having a staff who does not have an active fingerprint clearance. LPAs were unable to complete the Annual Inspection and will return to complete.. 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: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

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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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: 08/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of twelve residents reviewed did not have documentation of a medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2021
	Plan of Correction
1 2 3 4	Administrator agrees to obtain a medical assessment for resident, R1 by POC due date, 8/31/2021.

Type B

Section Cited

CCR

87507(d)

Admisson Agreements

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in five out of twelve residents reviewed did not have the Admission Agreement in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2021
	Plan of Correction
1 2 3 4	Administrator agrees to seek Admission Agreements and if unable to find them, will obtain new agreements from residents or their responsible parties by POC due date, 8/31/2021.

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: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

LIC809 (FAS) - (06/04)

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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: 08/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in four out of eight staff reviewed do not have results from a TB test which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2021
	Plan of Correction
1 2 3 4	Administrator agrees to make an appointment for each staff who does not have a TB test by POC due date 8/19/2021. If staff are unable to be tested due to a potential shortage of Tuberculin Skin Test antigen, they may request a waiver per PIN 19-22-ASC.

Type A

Section Cited

CCR

87355(e)(1)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in one out of eight staff reviewed does not have a valid fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2021
	Plan of Correction
1 2 3 4	Administrator agrees to submit self-certification indicating that staff will not return to facility until they have a valid fingerprint clearance by POC due date, 8/19/2021.

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: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

LIC809 (FAS) - (06/04)

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