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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 12/29/2021
Date Signed: 12/29/2021 01:02:42 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: 36DATE:
12/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Acting Administrator Cynthia MorrisTIME COMPLETED:
01:12 PM
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Licensing Program Analysts (LPAs) Victoria Willis and Caitlynn Felias arrived unannounced to conduct a Case Management inspection and met with Acting Administrator, Cynthia Morris.

Acting Administrator provided LPAs with an update for their Administrator Certification. Acting Administrator has been working with the Administrator Certification Section of Community Care Licensing Division to obtain an active Administrator Certificate. LPA will follow up.

LPAs also conducted a walk through of the facility and observed an area at the back of the facility with debris. Area is not blocked off but due to weather, residents are not currently spending time in the area. Per discussion with Cynthia, the debris is getting picked up by a garbage service today.

LPAs also observed three caregivers in Memory Care which appeared to be sufficient to ensure the care and supervision of residents.

LPAs have requested the following:
  • Picture showing that debris has been picked up
  • Screenshot from CCL website showing status of Administrator Certification.


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: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021
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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