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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 10/14/2021
Date Signed: 10/14/2021 03:46:22 PM

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: 31DATE:
10/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Administrator, Tracey MeaseTIME COMPLETED:
03:46 PM
NARRATIVE
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Licensing Program Analyst Willis arrived unannounced to conduct a Case Management Inspection and met with Administrator, Tracey Mease.

During complaint investigation LPA found deficiencies unrelated to the complaint investigation. The care plan for resident, R1 was most recently updated April 2020 despite resident having a significant change of condition. Additionally, regulation requires care plans to be updated a minimum of once per year.

LPA discussed resident, R2 who had a fall while bathing themselves. The resident care plan indicates that the resident is independent with bathing however, the resident's most recent physician's report indicates that resident is not able to bath themselves. Additionally, resident has started using a walker but the physician's report indicates they are ambulatory.

During this visit, LPA cleared multiple deficiencies and Letters of Deficiency Citations Cleared were provided to the Administrator. File review revealed that Admission Agreements for two of five residents (R3 and R4) previously reviewed on August 18, 2021 have not been found and one additional agreement reviewed for R2 was not signed by either party.

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: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2021
Section Cited

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87507 Admission Agreements (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be
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utilized as long as they are also signed and dated as prescribed above. This requirement has not been met as evidenced by file review indicating that 2 of five admission agreement are still missing and an additional admission agreement found was unsigned by both parties which is a potential risk to health and safety.
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Type B
11/04/2021
Section Cited

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87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever
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occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement has not been met as evidenced by file review indicating that R!'s care plan was not updated per regulation which both parties which is a potential risk to health and safety.
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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: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2