<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 01/07/2021
Date Signed: 01/11/2021 09:57:23 AM

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:ROB MATTHEWSFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: DATE:
01/07/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:TIME COMPLETED:
12:00 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
Regional Manager Carla Nuti-Martinez, Licensing Program Manager Hope DeBenedetti and Licensing Program Analyst Victoria Willis met with Licensee, John Alaux, Acting Administrator, Amanda North, Resident Care Coordinator, Trulynia Coiner, LVN along with Representatives of Pacifica Senior Living: Carl Knepler, President of Operations, Frank Perez, In House Council, Jackie Bobbitt, Vice President of Operations and Marlene Nelson, Director of Quality Assurance and Risk Management. Also in attendance was Josh Allen, RN with Allen Flores Consulting Group. The reason for the meeting is to conduct a Non-Compliance Conference regarding areas of concern. Due to COVID concerns the meeting was conducted virtually. A Change of Ownership is pending for Pacifica Senior Living and representatives from the Applicant were also in attendance.

RO has concerns about facilities ability to follow through with their COVID Mitigation Plan. LPA conducted outreach to facility numerous time virtually and via telephone calls to ensure facility Acting Administrator and Acting Manager/Applicant, Pacifica Senior Living understood their steps to mitigate the spread of COVID. CCL has conducted daily check-in calls from 12/08/20 to present as well as a call to Pacifica Senior Living Manager to discuss concerns on 12/22/20. LPA conducted a Virtual Visit on 10/21/20 and two Office Meetings were conducted via teleconference 12/31/20 and 1/4/21 to discuss areas of concern. In addition, California Department of Public Health and Local Public Health facility have attempted to provide additional guidance via telephone consultation and site inspections.

Continued in LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021
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 4
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: 01/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2021
Section Cited

1
2
3
4
5
6
7
Administrator - Qualifications and Duties. The administrator shall have the responsibility to: 3) Develop an administrative plan and procedures to ensure clear definition of lines of responsibility, equitable workloads, and adequate supervision. This requirement has not met as evidence by: Based on records
8
9
10
11
12
13
14
review, observations and interviews conducted with Licensee and Administrator failed to satisfactory follow guidelines that the Department recommended signage of Covid-19 after receiving 1st (+) staff which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
01/08/2021
Section Cited

1
2
3
4
5
6
7
Licenses or administrator Certificates; suspension, revocation or denial of application; grounds...(c) Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home. This requirement has not been met based on records review, observation &
8
9
10
11
12
13
14
facility failed to ensure implementation of a mitigation plan, staffing plan, cleaning schedule to mitigate the spread of COVID-19. After several attempts by the Department the facility has failed to provide the requested documentation which poses an immediate Health, Safety or Personal Rights risk to residents in care.
8
9
10
11
12
13
14
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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 01/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2021
Section Cited

1
2
3
4
5
6
7
HSC 1569.269 (a)(5)(6) Enumerated rights...(a) Residents... shall have...rights: (5) To be accorded safe, healthful, & comfortable accommodations...(6) To care, supervision, & services that meet their individual needs & are delivered by staff that are sufficient in numbers, qualifications & competency to meet their needs. This requirement has not been met by:
8
9
10
11
12
13
14
Based on records review, observations and interviews with Licensee and Administrator facilty failed to ensure the health and safety of clients in care by not having proper protocols in place.
8
9
10
11
12
13
14

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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 01/07/2021
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

During the meeting the following items were discussed:

· Lack of Sufficient Staffing
· Lack of training regarding proper donning and doffing of PPE and infection control
· Lack of covered trash bins to properly contain contaminated PPE in doffing areas
· Insufficient number of PPE stations with some stations containing insufficient supplies
· Required postings not posted in all required areas
· Lack of staff oversight
· Administrator Duties
· Location of screening station

Additional items were discussed from previous Office Meeting dated 10/8/2020, addressing concerns based on complaint investigation 21-AS-20200302162434

· Facility’s policy on observed changes of condition and seeking medical attention
· Facility’s policy on incident reporting including notifying the physician and responsible parties
· Facility’s policy on charting and documentation
· Staff and Resident Records

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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4