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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 08/24/2022
Date Signed: 08/24/2022 03:22:04 PM


Document Has Been Signed on 08/24/2022 03:22 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: 0DATE:
08/24/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Cinthya AlvarezTIME COMPLETED:
03:30 PM
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Licensing Program Manager Hope DeBenedetti, Licensing Program Analyst, Victoria Willis met in the Santa Rosa Regional Office with Administrator, Cinthya Alvarez. Pacifica representative, Leslie Quintanar and Regional Manager, Carla Nuti-Martinez were available via video conference.

This Office Meeting is being conducted to discuss the Stipulation and Waiver; and Order approved and signed by the Department of Social Services and all parties involved dated July 18, 2022.

Stipulation and Waiver; and Order states in part the following:
  • No later than 30 days after licensure,Pacifica shall identify to CCL an individual with the duty and authority to supervise and ensure compliance with all the terms of this stipulation and order. Individual will review all licensing reports and report to the Board of Directors the status of correction and perform monthly quality assurance audit of the facility using a tool approved by licensing.
  • Within three months of the execution of the stipulation, Pacifica shall retain a Vendor preapproved by licensing to provide a minimum of four hours of monthly training to all direct care staff and managers. *Details provided in Stipulation and Order.
  • Pacifica shall ensure that the facility has adequate oversight by a designated facility administrator who is in good standing with the Department, The administrator shall be the administrator of record for no more than one facility and at the facility for 40 hours per week.
  • Pacifica shall perform quarterly audits of medication and monthly audits of medication records. Audit reports shall be provided to CCL within five days of completion. Any errors shall have a plan of correction included in the audit report.



Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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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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: 08/24/2022
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Continued from LIC809
  • Pacifica understands that facility staff must be hired in numbers necessary to meet the needs of the residents. Units must not share direct care staff.*Details in Stipulation and Order.
  • Pacifica will ensure that the facility is clean, safe, sanitary and in good repair at all times.
  • Pacifica will report any unusual incident including, but not limited to client death or injury which requires medical treatment, any suspected physical or psychological abuse, and any physical plant changes and all unexplained absences. Must be reported by the next working day followed by a written report 7 days later.
  • A record of staff training required must be maintained and made available to CCL upon request
  • Facility call system and delayed egress shall at all times be fully operational. Facility shall use non -direct care staff to monitor facility's front desk.
  • The medication tech will not be a direct care staff but may provide support/back-up when not distributing medication.
  • Facility shall maintain separate housekeeping, maintenance and food service staff at all times, and staff breaks and lunch shall be staggered so there is adequate staff coverage.
  • Facility will submit monthly LIC500 Personnel Reports to CCl along with a census of each unit and any two-person assist identified.
  • Pacifica will ensure that timely medical care is obtained for facility residents and will ensure that all facility administrators, supervisors and caregivers follow the instructions and orders of skilled medical professionals regarding the care of clients who reside in the facility
  • Pacifica will ensure that facility is operated in strict compliance with the regulation and statures governing residential care facilities for the elderly.
  • During the period of probation, the Department in its sole discretion may conduct unannounced visits for the purpose of determining whether there is full compliance.

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

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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