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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 12/08/2022
Date Signed: 12/08/2022 03:47:02 PM


Document Has Been Signed on 12/08/2022 03:47 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:GAMINO, CINTHYAFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 40DATE:
12/08/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Administrator, Cinthya GaminoTIME COMPLETED:
03:56 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Legal Non-Compliance Case Management inspection and met with Administrator, Cinthya Gamino.

As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, the facility has submitted monthly reports to LPA that include an LIC500 that shows staffing, resident roster that includes how many residents are 2 person assists, and a Monthly Quality Assurance Audit that includes but is not limited to staffing, physical plant, dementia care, medication records and infection control. Administrator provided LPA with the Quarterly Audit that was conducted September 2022.

Facility provides monthly training to existing staff in order to comply with the Stipulation and Waiver, and Order and contracts with a vendor to ensure the staff training requirement is met. Administrator provided LPA with proof of training for Managers, Caregivers and Medication Technicians. LPA and Administrator discussed how the Administrator ensures all staff are trained per the requirement. Training was being conducted during this visit. LPA confirmed that new staff are trained within 30 days of hire.

LPA reviewed the most recent staff schedule to confirm that facility had sufficient staff for resident's needs. Per conversation with Administrator, they staff two caregivers for each unit on each shift to ensure sufficient staffing. Managers and Medication Technicians provide additional assistance for breaks and lunches, if needed.

Facility continues to submit Special Incident Reports within the regulatory time frame. LPA observed that facility is safe, sanitary and in good repair and that Covid protocols are being followed.

Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HEALDSBURG SENIOR LIVING COMMUNITY
FACILITY NUMBER: 496801635
VISIT DATE: 12/08/2022
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Continued from LIC809

Review of audits showed some minor instances of non-compliance however the instances were not significant or frequent enough to warrant a health and safety concern. Issues noted in the audit were immediately remedied by the facility.

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: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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