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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 09/02/2021
Date Signed: 09/02/2021 05:15:23 PM

COMPREHENSIVE INSPECTION
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: 30DATE:
09/02/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Administrator, Tracey MeaseTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analysts Willis and Gonzalez-Campos arrived unannounced to conduct an Annual Continuation inspection and met with Administrator, Tracey Mease.

The Annual Inspection was initiated on August 17, 2021 and continued to August 18, 2021 and today. LPAs conducted a review of medication and medication records for five residents. LPAs observed that three of five residents reviewed missed at least one dose of medication. The reason for the missed medication was not documented in the Medication Administration Record. Additionally, resident, R1 had PRN medication dispensed that was not documented in the Medication Administration Record. Resident, R2 had medication that was not input into the Centrally Stored Medication Record accurately with an incorrect prescription number and start date. Another resident had missed multiple days of medication due to the medication not being refilled timely. This error is addressed in a separate report.

LPA followed up on Plan of Corrections that were previously cited. LPA provided additional information to facility in order to clear deficiency. Conversation with facility staff indicated that they are preparing to initiate training for all Caregivers and Med Techs. Plan of correction for training was due August 25, 2021. Based on conversation with staff indicating that they anticipate having all staff trained in one month, LPA is allowing for an extension until October 1, 2021. All staff are to be trained per regulation by this date.

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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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 2
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: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2021
Section Cited

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year.
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This requirement is not met as evidenced by: Based on medication review, centrally stored medication log was not accurate in 5 of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.
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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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021
LIC809 (FAS) - (06/04)
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