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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 09/09/2022
Date Signed: 09/09/2022 01:48:07 PM

Document Has Been Signed on 09/09/2022 01:48 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:
09/09/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Cinthya GaminoTIME COMPLETED:
02:00 PM
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Licensing Program Analyst Willis arrived unannounced to continue the Annual Required Inspection that was started July 29, 2022 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. During visit LPA conducted a review of staff training files, resident medication and medication records, the facility's Emergency Disaster Plan and the Infection Control Plan. LPA discussed these items with the Administrator as well as items that are required per the Stipulation and Waiver; and Order approved and signed by the Department of Social Services and all parties involved dated July 18, 2022.

During the office meeting conducted August 24, 2022, the Administrator and Regional Director of Operations provided the plan and what documents they would use to ensure that the requirements of the Stipulation and Waiver, and Order are met. Pacifica representatives have provided and will continue to provide LPA with documents and correspondence to fulfill the requirement.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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