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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 12/29/2022
Date Signed: 12/29/2022 01:39:00 PM


Document Has Been Signed on 12/29/2022 01:39 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: 42DATE:
12/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator, Cinthya GaminoTIME COMPLETED:
01:50 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Cinthya Gamino.

Facility reported an incident where resident, R1 left the facility unsupervised and was observed by a staff member down the street from the facility. Review of resident's Physician's Report dated 6/21/22 indicated that R1 should be escorted by staff when leaving the community due to physical impairment. R1 is not diagnosed with dementia and the doctor did not indicate that the reason for a staff escort was due to cognitive delay or decline. R1 does not reside in a memory care unit.

Following elopement, the facility requested clarification from the doctor on whether R1 was able to go into the community alone and the doctor responded on 12/14/2022 via an updated Physician's Report that R1 was still unable to leave the facility without an escort due to weakness.

Per conversation with Administrator, they have communicated with the resident that they are not able to leave the community without an escort per their doctor's instruction. R1 understands and has agreed to not to leave the facility unassisted.

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: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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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