496801635-1-5-2021-21-AS-VWIS-BWYM39-20210105081444

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 01/04/2021
Date Signed: 01/05/2021 08:14:50 AM

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:	ROB MATTHEWS		FACILITY TYPE:	740
ADDRESS:	725 GROVE STREET		TELEPHONE:	(707) 433-4877
CITY:	HEALDSBURG	STATE: CA	ZIP CODE:	95448
CAPACITY:	82	CENSUS:	DATE:	01/04/2021
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Acting Administrator, Amanda North and Resident Care Coordinator, Trulynia Coiner, LVN		TIME COMPLETED:	01:40 PM

NARRATIVE

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Licensing Program Analyst Willis and Licensing Program Manager DeBenedetti met with Acting Administrator, Amanda North and Resident Care Coordinator, Trulynia Coiner, LVN. via teleconference due to Covid-19 precautions.

Parties spoke regarding items that were requested during and following an office meeting that was conducted December 30, 2020 as well as other areas of concern. Areas discussed included the following:

Staffing *CCL confirmed that staff are working overtime and facility is utilizing multiple staffing agencies. Facility has provided an updated LIC500 - Personnel Report but LPA required some clarifying information.
Training *Administrator showed LPA a document indicating that it was proof of training for donning and doffing of PPE and Infection Control and stated she will send to LPA.
Mitigation Plan *CCL has requested a more detailed Mitigation Plan than what has been provided. (Sample emailed to Acting Administrator)
N95 Fit testing *Facility has not yet conducted fit testing for N95s.

The following items are due by COB today:

Proof of training regarding donning and doffing PPE and Infection Control *Previously requested 12/17/20, 12/22/20 and 12/31/20.
Update LIC500 - Personnel Report which needs to specify which unit the caregivers are working in and specify who is a Med Tech.
Amount of current Hospice Residents. *Previously requested on 12/30/20
Plan for when fit testing will be completed for staff
Facility photos as discussed.
Updated Mitigation Plan *Due as soon as possible but no later than January 6, 2021.
Plan to ensure facility has virtual capabilities

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021

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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