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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 12/09/2021
Date Signed: 12/09/2021 02:25:56 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: 31DATE:
12/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Acting Administrtor, Cynthia MorrisTIME COMPLETED:
02:35 PM
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Licensing Program Analysts (LPA) Willis and Felias arrived unannounced to conduct a Case Management inspection and met with Acting Administrator, Cynthia Morris.

LPAs are following up regarding the Change of Administrator requested by the facility. Facility has submitted documentation to change the Administrator to Cynthia Morris. There was a delay in Cynthia receiving their Administrator Certification. Per conversation with Cynthia, she was able to remedy the situation today and anticipates having a valid Administrator Certificate by Monday, December 13, 2021 based on conversation she had with the Administrator Certification Section of Community Care Licensing Division.

LPA will continue to follow up.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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