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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 01/25/2021
Date Signed: 01/26/2021 01:40:50 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:ROB MATTHEWSFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: DATE:
01/25/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:TIME COMPLETED:
11:00 AM
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Licensing Program Analyst Willis and Licensing Program Manager DeBenedetti met with Administrator, Tracey Mease and Resident Care Coordinator, Trulynia Coiner, LVN along with representatives from Pacifica Senior Living, Jackie Bobbitt and Marlene Nelson via teleconference due to Covid-19 precautions.

Teleconference visit was conducted so CCL representatives could observe compliance with the facility Mitigation Plan. The following observations were made:
  • Facility has cohorted Covid positive residents to minimize exposure
  • PPE stations are set up outside of the Covid positive unit as well as throughout the unit
  • Facility has started documenting when they disinfect the facility to assist with infection control
  • Trash cans in resident bedrooms did not have lids. Acting Administrator previously indicated that they have been ordered but based on conversation today, they have not arrived.


Administrator was provided with the following:
  • Title 22 regulations pertaining to Administrator Qualifications and Duties
  • The facility non-compliance plan to ensure that actions are being followed.

Administrator to provide CCL the following:
  • Status of N95 fit testing and alternative masks for those that the mask did not fit
  • Detailed explanation of current staffing along with an updated LIC500
  • Documentation that staff have been trained on the facility's Mitigation Plan.
  • Proof of training requested January 21, 2021 must be received by COB today. Failure to provide complete proof of training will result in citations.
  • Proof that lidded trash cans for isolation rooms have been ordered.


No deficiencies were cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021
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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