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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 03/05/2021
Date Signed: 03/05/2021 03:31:17 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:MEASE, TRACEYFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: DATE:
03/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Tracey Mease and Resident Care Coordinator, Tru CoinerTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst met with Administrator, Tracey Mease and Resident Care Coordinator, Tru Coiner via tele-visit to observe Covid-19 precautions.

During the course of investigating complaints, concerns were raised over potential facility retaliation, administrator qualifications and duties and the facility’s policy on visitation. LPA and Administrator discussed the concerns and Administrator was provided copies of Title 22 regulations/Health & Safety Regulations, PINs and current county orders which directly relate to the concerns. Additionally, violations to regulation were revealed during investigation unrelated to the complaint allegations and are being cited as follows:
  • During investigation LPA requested documents from resident, R1's file. Per facility staff, they were unable to find R1's file.
  • LPA reviewed training for staff and discovered that of the thirteen staff reviewed, ten staff do not have First Aid training.


LPA also discussed the outstanding Proof of Correction that was cited during the 1/7/2021 Office Meeting that was to be corrected 1/8/2021. To date, proof that all staff have received training on the Mitigation Plan has not been received. Proof that staff have been trained on the Mitigation Plan is due no later than 3/8/2021.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 496801635
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2021
Section Cited

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87411 Personnel Requirements - General - (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on review of thirteen staff training records, the licensee did not ensure that ten of thirteen staff reviewed have
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First Aid training which is an immediate risk to health and safety of residents in care.
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Type B
03/12/2021
Section Cited

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87506 Resident Records - Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: Based on interview of facility staff licensee did not ensure that records were retained and made available to CCL which poses a potential
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risk to health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2021
LIC809 (FAS) - (06/04)
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