496801635-11-17-2021-21-AS-CMAZ-C8WREV-20211119115808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 11/17/2021
Date Signed: 11/17/2021 02:52:16 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
10/07/2021 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20211007160619

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:	DATE:	11/17/2021
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Administrator, Dwayne Davis		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Staff did not respond to call button timely
Facility did not notify responsible party of resident fall
Facility did not provide records to responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegations and met with Administrator, Dwayne Davis.

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

Complaint alleges that following a fall, a resident pulled the pull cord but a caregiver did not respond to the call button timely and that the responsible party was not notified of the fall. Staff interview indicated that they responded to the call button immediately and called the resident's responsible party while still in the resident's room. Facility does not have a monitoring system that shows the response time for their pull cords. Attempt to gather clarifying information from others was unsuccessfull.

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: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

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-20211007160619

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: 11/17/2021

NARRATIVE

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Continued from LIC9099

Complaint alleges that the facility did not provide requested records timely. LPA was unable to obtain evidence that request was made in writing, which is a requirement of regulation.

A finding that the complaint allegations that Staff did not respond to call button timely, Facility did not notify responsible party of resident fall and Facility did not provide records to responsible party was unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegation occurred.

No deficiencies cited during inspection.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

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