496801635-10-14-2021-21-AS-HDBI-C7ZVLQ-20211021163219

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 10/14/2021
Date Signed: 10/14/2021 03:58:44 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
06/28/2021 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20210628110701

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: 31	DATE:	10/14/2021
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Administrator, Tracey Mease		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff caused injury to resident while in care
Insufficient care and supervision resulting in a resident fall
Staff did not inform responsible party of resident change in condition
Resident not accorded dignity in their relationship with staff

INVESTIGATION FINDINGS:

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

During investigation LPA reviewed records and conducted interviews.

Staff did not inform responsible party of resident change in condition – Complaint alleges that the Administrator did not update resident’s responsible party while resident was in the hospital. Based on interviews, the responsible party was updated by hospital staff.

Staff caused injury to resident while in care – Complaint alleges that resident was injured during an attempt by staff to assist resident with incontinence care despite resident not needing incontinence care. Care Plan dated April 2020 indicated that resident was independent with toileting.

Continued on LIC9099C

Unsubstantiated

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: 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.

LIC9099 (FAS) - (06/04)

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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
06/28/2021 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20210628110701

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: 31	DATE:	10/14/2021
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Administrator, Tracey Mease		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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9

Staff did not inform responsible party regarding resident's fall

INVESTIGATION FINDINGS:

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

During investigation LPA reviewed records and conducted interviews.

Staff did not inform responsible party regarding resident's fall – Complaint alleges that resident’s responsible party was not notified when they fell. Further interview revealed that the responsible party was notified by staff that the resident fell and was being taken to the hospital. Narrative Charting also indicated that resident’s responsible party was notified of resident’s fall.

This agency has investigated the complaint alleging Staff did not inform responsible party regarding resident's fall. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies cited during this inspection.

Unfounded

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210628110701

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: 10/14/2021

NARRATIVE

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Continued from LIC 9099

Review of narrative charting for resident, R1 noted an incident where resident refused to sleep with a pad or brief. The charting does not indicate that staff was forceful with attempt to provide incontinence care. Involved staff no longer works at facility and attempts to interview them were unsuccessful.

Insufficient care and supervision resulting in a resident fall – Complaint alleges that resident, R1 was a known fall risk. Review of resident’s care plan dated April, 2020 indicated that resident was independent with all Activities of Daily Living including ambulation but they used a walker. Care plan did not indicate that resident was a fall risk. According to multiple staff interviewed, resident was not known as a fall risk and was independent with many activities of daily living.

Resident not accorded dignity in their relationship with staff – Complaint alleges that staff hurt and beat resident but was not able to provide the name of the staff or other evidence supporting the allegation.

A finding that the complaint allegations Staff did not inform responsible party of resident change in condition, Staff caused injury to resident while in care, Insufficient care and supervision resulting in a resident fall, and Resident not accorded dignity in their relationship with staff 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 during this inspection.

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

LIC9099 (FAS) - (06/04)

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