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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 09/23/2021
Date Signed: 09/23/2021 01:53:59 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 COMMUNITYFACILITY NUMBER:
496801635
ADMINISTRATOR:MEASE, TRACEYFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 34DATE:
09/23/2021
UNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Resident Services Director, Tru CoinerTIME COMPLETED:
01:53 PM
ALLEGATION(S):
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Residents care needs are not being met
INVESTIGATION FINDINGS:
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Licensing Program Analysts Willis arrived unannounced to deliver findings regarding the above complaint allegation and met with Resident Services Director, Tru Coiner.

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

Residents care needs are not being met – Complaint alleges that resident needs are not being met partly due to insufficient caregiving staff and staff not being adequately trained. Complaint alleges that residents’ incontinence needs, activities of daily living and housekeeping needs are not being met. Pictures of heavily soiled briefs were provided with an explanation that soiled briefs were due to lack of supplies and insufficient staffing. Interviews with facility staff revealed that it was the responsibility of the residents’ responsible parties to provide incontinent supplies. When asked if the facility had backup incontinence briefs, staff indicated that caregivers would have to request supplies from a manager or go to Skilled Nursing to obtain supplies.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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 5
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 COMMUNITYFACILITY NUMBER:
496801635
ADMINISTRATOR:MEASE, TRACEYFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 34DATE:
09/23/2021
UNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Resident Services Director, Tru CoinerTIME COMPLETED:
01:53 PM
ALLEGATION(S):
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Food being served is not good quality
Facility is not reporting change of conditions to responsible parties
INVESTIGATION FINDINGS:
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Licensing Program Analysts Willis arrived unannounced to deliver findings regarding the above complaint allegations and met with Resident Services Director, Tru Coiner.

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

Facility is not reporting change of conditions to responsible parties - Complaint alleges that facility is not reporting change of conditions to responsible parties. Attempts to gather additional information regarding this allegation was unsuccessful.

Food being served is not good quality – Complaint alleges that there are “dietary concerns” but did not specify what they were. Attempts to gain clarification were not successful. LPA observations during Annual inspection on August 18, 2021 did not indicate wide-spread quality issues though LPA did observe expired juice and facility was cited.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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: 09/23/2021
NARRATIVE
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Continued from LIC9099A

A finding that the complaint allegation facility is not reporting change of conditions to responsible parties and food being served is not good quality was unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegation occurred. We have therefore dismissed the complaint.

No deficiencies cited.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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: 09/23/2021
NARRATIVE
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Continued from LIC9099

During a visit to Memory Care on July 20, 2021 LPA confirmed through observation that there were no back-up incontinent supplies, however, during subsequent visits LPA observed incontinence supplies in a storage closet in Memory Care. Allegations that facility lacks sufficient staffing, staff are not trained and housekeeping needs are not being met were previously substantiated and citations were issued. Multiple interviews and a review of documents including staff schedule and resident care plans show that there were at least four residents in Memory Care and one in Assisted Living who were designated as Total Assist or Two-Person assist and facility failed to have enough staff on shift to meet their needs.

The allegation that residents care needs are not being met 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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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: 09/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2021
Section Cited
CCR
87464(d)
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87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services
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Facility has hired additional staff and are actively training staff to meet the training regulation by October 1, 2021 to ensure residents' care needs are being met. Additionally, incontinence supplies are being stored in Memory Care and per conversation with facility, an adequate supply will continue to be stored there so it is easily
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specified below, either directly or through outside resources. Requirement is not met as evidenced by: Based on interviews, record review and observation, the licensee did not comply with the section cited above with at least four residents not receiving assistance per their care plans which poses an immediate risk to health and safety.
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accessible to staff who need it. Deficiency is cleared.
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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: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5