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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 03:44:03 PM


Document Has Been Signed on 12/08/2022 03:44 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 - IncidentUNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Administrator, Cinthya GaminoTIME COMPLETED:
03:53 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Cinthya Gamino arrived later.

During Non-Compliance Case Management inspection LPA followed up on a recent incident where staff (S1) observed another staff (S2) pushing a resident in a wheelchair "too fast" resulting in the resident waving their hands, trying to hit S2 and eventually grabbing the fence. S1 then reported that when resident was standing, holding onto the fence S2 moved the wheelchair causing the resident to fall.

Per S2, when the resident grabbed onto the fence, S2 attempted to remove their hands from the fence and reposition the wheelchair back under the resident as it had moved back when resident stood up but the resident fell.

The local police and CCL were notified and S2 has since resigned from their position. LPA reminded Administrator to notify the Long Term Care Ombudsman and they agreed to send the report to them.

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
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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