496801635-9-2-2021-21-AS-HDBI-C7J5BS-20211005194914

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 09/02/2021
Date Signed: 09/02/2021 04:59:09 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
06/04/2021 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20210604151632

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:	01:58 PM
MET WITH:	Administrator, Tracey Mease		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility has not notified residents and responsible parties about the family council
Facility is not ensuring medication is refilled timely

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.

During investigation, LPA conducted interviews, made observations and reviewed documents.

Facility has not notified residents and responsible parties about the family council - Allegation indicated that the facility has not provided information regarding the family council to resident's responsible parties. Based on interviews and LPA observations, the facility has not designated an area for the family council to display meeting notices, minutes, and newsletters as required by regulation.

Facility is not ensuring medication is refilled timely - Complaint alleges that some residents medications are not being refilled timely and are running out. LPA review of five resident's medication revealed one medication that ran out on August 31, 2021 and was not ordered until today, September 2, 2021.

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)

Page: 1 of 4

Control Number 21-AS-20210604151632

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

The allegation Facility has not notified residents and responsible parties about the family council and Facility is not ensuring medication is refilled timely is 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-20210604151632

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 87465(a)(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.	1 2 3 4 5 6 7	Facility agrees to submit planned training day for all Medtechs to be trained on medication refill policy by POC due date 09/03/2021. Training to be conducted no later than 09/10/2021.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on LPA medication review, the licensee did not comply with the section cited above by one of five residents reviewed not having medication filled timely which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 09/06/2021 Section Cited HSC 1512.5(d)	1 2 3 4 5 6 7	1512.5 Family councils (d) Family councils shall also be provided adequate space on a prominent bulletin board or other posting area for the display of meeting notices, minutes, and newsletters. This requirement is not met as evidenced by: LPA observation, indicating the facility has not designated an area notifying reponsible parties of the family council	1 2 3 4 5 6 7	Facility agrees to submit a photo showing designated area for family council notification and information to CCL by POC due date 09/06/2021.
	8 9 10 11 12 13 14	which poses a potential 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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