496801635-11-23-2021-21-AS-VWIS-C92VST-20211123154204

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 11/23/2021
Date Signed: 11/23/2021 03:42:19 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 COMMUNITY		FACILITY NUMBER:	496801635
ADMINISTRATOR:	DAVIS, DWAYNE		FACILITY TYPE:	740
ADDRESS:	725 GROVE STREET		TELEPHONE:	(707) 433-4877
CITY:	HEALDSBURG	STATE: CA	ZIP CODE:	95448
CAPACITY:	82	CENSUS: 41	DATE:	11/23/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Cynthia Morris, LVN		TIME COMPLETED:	03:51 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst Victoria Willis and Regional Manager Carla Nuti-Martinez conducted a Case Management visit today to ensure staffing and Administrative Representation over the holiday weekend, since Administrator Dwayne Davis gave notice on November 22, 2021. The following information was received from Cynthia Morris, LVN (which she followed with an email); Cynthia Morris, LVN will be assisting Carmen Iniguez, Resident Care Coordinator and newly hired Administrator and Director of Nursing Mary Webster. Census in AL and MC = 41 total (24 AL and 17 MC) Staffing as follows through Monday 11/29/2021 AL: AM 1 PM 1 NOC 1 with a floating med tech for each shift MC: AM 3 PM 3 and NOC 2 with a floating med tech for each shift additional 1:1 coverage on shifts as needed for specific residents. Manager on Duty* (MOD) coverage over the Holiday is as follows: Wed: 11/24/21 Deb Kolman, RN Charge nurse Jeff Goodfellow RN Charge nurse Diana Avila, Medical records, Staffing Mitchell Moore, Business Office Cindy Morris, ED Sp. LVN Mar Macaspac, RN, DON Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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
	VISIT DATE: 11/23/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC809
Thurs: 11/25/21
Jeff Goodfellow RN Charge nurse
Erika Gonzalez, Food Service Director

Friday: 11/26/21
Jeff Goodfellow RN Charge nurse
Mitchell Moore, Business Office
Mar Macaspac, RN, DON

Sat: 11/27/2021
Jeff Goodfellow RN Charge nurse
Cinthya Gamino, Community Relations Director
Mar Macaspac, RN, DON

Sun: 11/28/21
Jeff Goodfellow RN Charge nurse
Mar Macaspac, RN, DON

On Call:
Leslie Quintanar, Regional Director of Operations
Mary Webster, Interim NHA/RCFE
Diana Avila, Medical records, Staffing

Facility has three staffing agencies on standby (2 for SNF and 1 for AL/MC).

AL/MC staffing schedule received during visit and SNF staffing schedule received during visit

At this time facility does not have any COVID positive residents or staff (testing is being done after an exposure to a COVID positive visitor). Mitigation Plan being followed - screening upon entry for visitors and staff.
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: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2