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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 07/29/2022
Date Signed: 07/29/2022 04:43:49 PM


Document Has Been Signed on 07/29/2022 04:43 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:ALVAREZ (GAMINO), CINTHYAFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 39DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Cinthya GaminoTIME COMPLETED:
04:53 PM
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Licensing Program Analyst Willis arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Cinthya Alvarez.

Upon arrival, LPA was screened by the receptionist and asked to fill out a questionnaire with standard Covid-19 screening questions. LPA initiated a tour of the facility around 9:30 am with the administrator and made the following observations: Facility has a main building that is designated for assisted living residents and includes common areas, a dining room, kitchen, salon, employee break room and an area for activities. Two additional buildings are on the premises and they are designated for Memory Care residents. All buildings were a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature was tested in each building and read at 110, 114 and 106 degree F which are within allowable range of 105 to 120 degrees F. Bathrooms had required bath mats and grab bars. Facility maintains a garden and livestock including chickens, goats and ducks. Garden and animals appeared healthy. Facility is currently in the process of constructing another building on the property as well as creating additional parking. Construction areas are fenced off to ensure resident safety.

Fire extinguishers were last serviced April, 2022. Facility's fire system is maintained by a vendor. The most recent service of the entire system was conducted December, 2021 but the vendor recently came out on a service call due to an alarm that was malfunctioning. Per conversation with the Maintenance Director, the issue has been remedied and the system is working fine now. Exit doors for the Memory Care unit are alarmed and are delayed egress. Door alarms were functional during inspection.

Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HEALDSBURG SENIOR LIVING COMMUNITY
FACILITY NUMBER: 496801635
VISIT DATE: 07/29/2022
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Continued from LIC809

LPA reviewed ten resident files and nine staff files. Per conversation with Administrator, they are actively reviewing files to ensure they are complete. LPA will provide Administrator with a copy of regulation 87412 - Personnel Records. Training records will be reviewed at a later date.

Facility has adequate Personal Protective Equipment (PPE) that is stored accessible to staff who need it. Facility has carts that are already stocked with supplies in case of a Covid outbreak.

LPA was unable to complete the Annual Inspection and will return to complete.

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: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
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