496801635-10-28-2021-21-AS-KMOA-C8TRFY-20211116115956

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 10/28/2021
Date Signed: 10/28/2021 02:44:28 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-20211007083602

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: 30	DATE:	10/28/2021
		UNANNOUNCED	TIME BEGAN:	11:52 AM
MET WITH:	Administrator, Dwayne Davis		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility has not completed a reappraisal with resident's responsible party
Administrator is not fulfilling their duties

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 documents and made observations.

Facility has not completed a reappraisal with resident's responsible party - Complaint alleges that the facility has not completed a reappraisal with a resident's responsible party. Interviews with facility staff confirm that facility has not completed reappraisals for many residents, which includes the resident in question, per regulation which requires that reappraisals are completed with a resident and their responsible party, if they have one, at least once per year.

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: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

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 4

Control Number 21-AS-20211007083602

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: 10/28/2021

NARRATIVE

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Continued from LIC9099

LPA previously cited a deficiency of this regulation on October 14, 2021 and the correction was to have all reappraisals completed by November 4, 2021. Due to a management change, there has been a delay in completing the reappraisals, however, facility staff verbally told LPA that their plan is to conduct five reappraisals per week until all are completed. LPA is modifying the previous correction to request a written timeline of when reappraisals are planned to be completed by November 4, 2021.

Administrator is not fulfilling their duties - Complaint alleges that the Administrator has not followed through with a request for a care conference. Document review and interview confirmed that a care conference has not occurred. Interview with previous Administrator also revealed that the Administrator was not fully knowledgeable regarding the reappraisal process. Additionally, Administrator was unable to obtain financial documentation that LPA requested due to them not having knowledge on how to access document.

The allegations that Facility has not completed a reappraisal with resident's responsible party and the Administrator is not fulfilling their duties are Substantiated. A finding that the complaints are 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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20211007083602

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: 10/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/04/2021 Section Cited CCR 87405(b)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. Based on interviews, the licensee did not comply with the section cited above by not showing adequate knowledge of the reappraisal	1 2 3 4 5 6 7	Administrator to provide facility policies and protocol indicating what the responsibilities and duties of the Administrator are pursuant to Regulation 87208(a)(4) and (5) by POC due date, 11/4/2021.
	8 9 10 11 12 13 14	process and facility financial records protocol which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

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-20211007083602

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:	10/28/2021
		UNANNOUNCED	TIME BEGAN:	11:52 AM
MET WITH:	Administrator, Dwayne Davis		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility did not notify responsible party of resident's change of condition

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 documents and made observations.

Facility did not notify responsible party of resident's change of condition - Complaint alleges that resident had a change of condition requiring additional care that was not reported to the resident's responsible party. Review of financial documents did not indicate a fee increase for care for noted resident. Due to reappriasals not being completed, LPA was unable to review accurate documentaiton of a change of condition.

A finding that the complaint allegation that facility did not notify responsible party of resident's change of condition was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred.

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: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4