496801635-7-28-2021-21-AS-HDBI-C7J5BT-20211005194917

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 07/28/2021
Date Signed: 07/28/2021 05:49:04 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: 34	DATE:	07/28/2021
		UNANNOUNCED	TIME BEGAN:	03:31 PM
MET WITH:	Resident Service Director, Tru Coiner.		TIME COMPLETED:	05:50 PM

ALLEGATION(S):

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Insufficient Staffing
Staff are not trained
Facility is not providing adequate activities

INVESTIGATION FINDINGS:

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Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegations and met with Resident Service Director, Tru Coiner.

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

Complaint alleges that the facility has insufficient staffing. Multiple interviews have indicated that the facility iis having staffing issues. Review of the staff schedule for July 2021 shows that Memory Care had multiple days where there was one caregiver and one medication technician and at least one day where there was one medication technician despite at least four of thirteen residents being "Total Assist" for their care needs. Additionally, interviews revealed that there are currently no housekeepers in Memory Care or Assisted Living and caregivers are expected to clean the facility in addition to providing care.

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: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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

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: 07/28/2021

NARRATIVE

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Continued from LIC9099

Complaint alleges that staff are not trained. Per conversation with Resident Services Director, facility is transitioning to a new training program so no additional training has been conducted for existing staff despite LPA being provided a training schedule on March 5, 2021. Training was to be completed March 19, 2021.

Complaint alleges that the facility is not being provided adequate activities. LPA observed that the area outdoor designated for residents has multiple areas that are closed off due to construction. The remaining location where residents are able to go is accessible by one door that closes automatically behind the person. Interviews revealed that residents do not have a key to the door and must be accompanied by a staff. LPA observed that in order to vacate the area without a key, a person must step over or go under caution tape.

The allegations that facility has Insufficient Staffing, Staff are not trained and facility is not providing adequate activities 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.

Two Civil Penalties in the amount of $250 each and totaling $500 are being assessed for repeating the same violations within a 12 month period.

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: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/29/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Sec. 87608	1 2 3 4 5 6 7	Facility agrees to submit plan explaining how they will ensure sufficient staffing to care for residents needs by POC due date, 7/29/2021. A Civil Penalty is being assessed in the amount of $250 for repeating the same violation within a 12 month period.
	8 9 10 11 12 13 14	Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. Requirement has not been met based on: Per interviews and document review, facility does not have sufficient staffing. This is an immediate risk to health and safety.	8 9 10 11 12 13 14
Type B 08/25/2021 Section Cited HSC 1569.625(b)	1 2 3 4 5 6 7	1569.625 Staff training; legislative findings; contents (b) The department shall adopt regulations to require staff members of RCFEs who assist residents with personal activities of daily living to receive appropriate training	1 2 3 4 5 6 7	Facility agrees to submit proof of training for all staff based on their position per Health and Safety Code 1569.625(b) and 1569.69 by POC due date, 8/25/2021. A Civil Penalty is being assessed in the amount of $250 for repeating the same violation within a 12 month period.
	8 9 10 11 12 13 14	This requirement has not been based on: Interviews and document review revealed that staff have not received additional training per the training schedule. This is a potential risk to the health and safety of residents 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: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/02/2021 Section Cited CCR 87219(h)(2)	1 2 3 4 5 6 7	87219 Planned Activities (h) Facilities shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas which are easily accessible to residents and protected from traffic. Gardens or yards shall be sufficient in size, comfortable and appropriately equipped for outdoor use.	1 2 3 4 5 6 7	Facilty agrees to submit a written plan indicating how they will ensure that activites are provided to residents that meet this regulation by POC due date, 8/2/2021.
	8 9 10 11 12 13 14	Licensee did not meet requirement as evidence by: Per LPA observation and interviews, the outdoor activity area is not currently easily accessible due to the ongoing construction. This is a potential risk to the Personal Rights of residents in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

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