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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 02/14/2022
Date Signed: 02/14/2022 02:55:16 PM


Document Has Been Signed on 02/14/2022 02:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:HEALDSBURG SENIOR LIVING COMMUNITYFACILITY NUMBER:
496801635
ADMINISTRATOR:MORRIS, CYNTHIAFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 38DATE:
02/14/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Executive Director, Jeffrey VonwalTIME COMPLETED:
03:05 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 Analysts Willis and Felias arrived unannounced to conduct a Case Management-Legal/Non-compliance Inspection and met with Executive Director, Jeffrey Vonwal. Current Administrator, Cynthia Morris arrived later. Jeffrey has recently been hired and the facility is currently in the process of submitting documents to CCL for a change of administrator.

Upon arrival, LPAs were greeted by the receptionist. LPAs took their own temperature and signed in. LPAs later requested that receptionist describe the process of screening visitors. Receptionist confirmed that they screen visitors and conduct vaccination verification per PIN 22-07-ASC. LPAs observed a screening log for staff as well. Staff are screened when they start their shift. LPAs were provided an updated Mitigation Plan dated February 11, 2022 and it was reviewed during this inspection. LPAs conducted a walk-through of facility to address compliance with the facility Mitigation Plan. LPAs observed that there were no Covid-19 Posters in Assisted Living or Memory Care. The posters observed during previous visits at facility entrance appear to have been removed. Per Medication Technician, facility is checking resident's temperatures daily. Med Tech provided LPAs with a log that showed daily temperatures for Assisted Living residents up until Thursday, February 10, 2022. Med Tech was unsure why documentation for Friday through today are missing. PPE was sufficient and stored in a room accessible to staff who need it. Housekeeping staff confirmed that they disinfect at lease once per day.

LPA provided the following guidance:
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: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022
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 1