496801635-9-2-2021-21-AS-HDBI-C75TZT-20210923151051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 09/02/2021
Date Signed: 09/02/2021 05:12:27 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
08/10/2021 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20210810151709

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: 30	DATE:	09/02/2021
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Administrator, Tracey Mease		TIME COMPLETED:	05:11 PM

ALLEGATION(S):

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Facility is not clean
Facility appliances are in disrepair
Facility is not providing hygiene products

INVESTIGATION FINDINGS:

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Licensing Program Analysts Willis and Gonzalez-Campos arrived unannounced to deliver findings regarding the above-mentioned complaint allegations and met with Administrator, Tracey Mease.

Facility is not clean – Complaint alleges that lack of adequate housekeeping staff is resulting in the facility not being cleaned. Based on interviews, facility has a staffing shortage including housekeeping which has resulted in resident rooms not being cleaned on the established cleaning schedule with at least two residents going multiple weeks without having their apartments cleaned. Other interview indicated that family is coming in to clean.

Facility appliances are in disrepair – Complaint alleges that there are two broken washers and one broken dryer in Memory Care. During inspection, LPA observed at least one broken washer in Memory Care. Additionally, the oven door in the kitchen does not close completely.

Continued on LIC9099C

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210810151709

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
	VISIT DATE: 09/02/2021

NARRATIVE

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Continued from LIC9099

Facility is not providing hygiene products – Complaint alleges that the facility is not providing toilet paper. Photographs of empty toilet paper rolls in Memory Care were also provided. Multiple interviews indicated that the facility did not have sufficient toilet paper causing some residents to have to go to reception to request toilet paper, which was not always available.

The allegations that facility is not clean, facility appliances are in disrepair and facility is not providing hygiene products are 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.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210810151709

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: 09/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/03/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews and observation, the	1 2 3 4 5 6 7	Facility agrees to submit a written plan indicating when noted items will be replaced or repaired by POC due date, 9/3/2021. Facility has hired a housekeeper and provided CCL with their plan to have resident apartments cleaned weekly.
	8 9 10 11 12 13 14	licensee did not comply with the section cited above by having appliances in disrepair and not cleaning resident rooms for multiple weeks due to lack of housekeeping staff which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type A 09/03/2021 Section Cited CCR 87307(a)(3)(D)	1 2 3 4 5 6 7	87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:	1 2 3 4 5 6 7	Facility agrees to submit the last three invoices for toilet paper by POC due date, 9/3/2021.
	8 9 10 11 12 13 14	(D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by: Based on interviews and photographs, the licensee did not comply with the section cited above by residents not always having tiolet paper in their rooms which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

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: 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

LIC9099 (FAS) - (06/04)

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