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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 11/26/2021
Date Signed: 11/26/2021 05:41:39 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:DAVIS, DWAYNEFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 41DATE:
11/26/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Cinthya GaminoTIME COMPLETED:
11:20 AM
NARRATIVE
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Regional Manager (RM) Carla Nuti-Martinez conducted a visit today to ensure adequate staffing at facility. RM met with Community Relations Director, Cinthya Gamino. RM toured the buildings and grounds. The following information was received;

Census: 40; all residents have returned from Thanksgiving Day outings with family and friends
MC: 16 (1 in SNF on property)
AL: 24

Staff:
AM:
MC: 2 direct care 1 roving med tech (1:1 for resident listed as R1 is off today so no 1:1) *a third staff was called to come in during the visit to ensure 3 direct care staff and 1 med tech (roving).
AL: 1 direct care and 1 roving med tech
PM:
MC: 3 direct care 1 roving med tech
AL: 1 direct care and 1 roving med tech
NOC:
MC: 2 direct care and 1 roving med tech
AL: 1 direct care and 1 roving med tech

Manager on Duty: Cynthia Gamino until 5pm, Carmen I, Med Tech. until 2pm
Responsible person in absence of Administrator: Med Tech on each shift

Continued on 9099C
SUPERVISOR'S NAME: Wes BeechamTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2021
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 3
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: 11/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2021
Section Cited

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All facilities shall have a qualified and currently certified administrator.... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible
Type A
11/26/2021
Section Cited

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RM observed staff not knowing who the Administrator is as well as staff unsure who the designated substitute is when Administrator is not on shift. Thsi poses an immediate Health and Safety Risk.
Type A
11/26/2021
Section Cited

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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... RM observed 1 staff in MC (second staff was at lunch) several 2 person assists and one resident who requires close observation). This poses an immediate Health and Safety Risk.
Type A
11/26/2021
Section Cited

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POC continued
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: Wes BeechamTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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
VISIT DATE: 11/26/2021
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RM checked in with facility on November 25, 2021 at 1:21pm. RM contacted the main line and the phone rolled into vm for Cinthya Gamino, Community Relations Director, RM proceeded to call two more times and and each time the phone rolled to vm. RM left a message on CG's vm and contacted the Manager listed on Duty provided by Leslie Quintanar, Regional Director of Operations on November 24, 2021. (RM also emailed LQ listed as "on-call" manager and did not receive a response until 12:59p November 26, 2021.)

The Managers listed on the "Manager On Duty" document provided to CCL stated they did not oversee the AL/MC; Staff AB had left at 2pm and works in the SNF, she was unaware of who was covering AL/MC, staff JG was staying in the cottage on property but was not at the facility, he was unaware who was covering AL/MC, EG was working the kitchen. None of the three had knowledge of who was covering the AL/MC. RM had to have staff JG go to the facility and locate the Med Tech and provide their contact number. RM also contacted Mary Webster from the "On-Call" list and was told she was not on property and did not have contacts for the AL/MC, she took RM's contact number to try and get assistance.

RM made contact with the Med Tech at 2:45p, they confirmed adequate staffing in AL and MC. They confirmed the census at the time as; 8 residents in AL and 15 in MC due to off-site visits with family and friends for the Holiday. Med Tech confirmed they were in charge on the AL/MC side.

RM confirmed the staffing for the NOC and learned this morning (11/26) there was a call off so the Med Tech/Resident Care Coordinator stayed until 2am to cover the shift.

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.

*Facility will ensure by November 29, 2021 an Administrator with their paperwork is on file with the Department.

*Facility will ensure ALL staff including, SNF RN MOD's, are aware of who is covering the AL/MC on all shifts in the event of an emergency.

Appeal rights given. Electronic Signatures on File.

SUPERVISOR'S NAME: Wes BeechamTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2021
LIC809 (FAS) - (06/04)
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