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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 11/03/2022
Date Signed: 11/03/2022 03:25:14 PM


Document Has Been Signed on 11/03/2022 03:25 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
SANTA ROSA RO, 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: 44DATE:
11/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Cinthya GaminoTIME COMPLETED:
03:35 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Cinthya Gamino.

LPA is following up regarding a recent incident involving resident, R1 who had a fall that resulted in a fracture. Resident had an event where they slid down the couch onto their side. Per chart notes and staff interview, R1 did not complain of pain at that point and slept through the night. The following morning, R1 complained of pain so was sent to the hospital where they were diagnosed with a fracture. R1 was not identified as needing 1:1 supervision.

During inspection, LPA learned about another incident where resident, R2 had a fall that was un-witnessed. Once found, staff assessed resident and sent them to the hospital. Per Administrator, they were given conflicting reports about whether resident was diagnosed with a fracture. Resident was eventually admitted to a skilled nursing facility where they passed away approximately two weeks later. R1 was not identified as needing 1:1 supervision.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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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