496801635-3-5-2021-21-AS-KMOA-BZ2QAF-20210312105953

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 03/05/2021
Date Signed: 03/05/2021 03:26:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/05/2021 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20210105105152

FACILITY NAME:	HEALDSBURG SENIOR LIVING COMMUNITY		FACILITY NUMBER:	496801635
ADMINISTRATOR:	ROB MATTHEWS		FACILITY TYPE:	740
ADDRESS:	725 GROVE STREET		TELEPHONE:	(707) 433-4877
CITY:	HEALDSBURG	STATE: CA	ZIP CODE:	95448
CAPACITY:	82	CENSUS:	DATE:	03/05/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator, Tracey Mease and Resident Care Coordinator, Tru Coiner		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility has insufficient staffing to meet the residents’ needs
Facility did not notify responsible party when resident had a change of condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst met with Administrator, Tracey Mease and Resident Care Coordinator, Tru Coiner via Televisit to deliver findings regarding the above complaint allegations. Visit was completed via tele-visit to observe Covid-19 precautions.

During investigation LPA interviewed staff, residents and various outside parties, including but not limited to responsible parties, medical providers and long term care ombudsman, conducted virtual tours of the facility on 12/10/20, 1/4/21, 1/6/21, 1/14/21, 1/25/21 and 2/11/21 and reviewed various documents such as resident, staff and facility records, communication records, medical records and pictures.

Facility has insufficient staffing to meet the residents’ needs - Complaint alleges that the facility is understaffed because many staff members were absent from testing positive for COVID-19. Based on interviews and LPA observations during various virtual tours at the facility LPA learned that facility had experienced insufficient staffing/staffing shortages in Memory Care, partially due to a recent outbreak of Covid-19.
Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210105105152

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/05/2021

NARRATIVE

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Continued from LIC9099

Facility did not notify responsible party when resident had a change of condition - Complaint alleges that the doctor for two Covid positive residents was not notified by the facility of their change of condition and was instead told by the families of the residents. Interviews confirmed that resident, R2's family was the first to notify resident's doctor four days after the resident tested positive for Covid and the doctor was not notified by the facility.

The allegations that Facility has insufficient staffing to meet the residents’ needs and that Facility did not notify responsible party when resident had a change of condition is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210105105152

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not ensure sufficient staffing to provide services to	1 2 3 4 5 6 7	Staffing situation has improved based on more recent interviews with staff and community members. Administrator agrees to submit updated LIC500 for all staff by POC due date 3/6/2021.
	8 9 10 11 12 13 14	residents which is an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
Type A 03/06/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of Resident. Licensee shall ensure that residents are regularly observed for changes in physical...functioning & that...assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of... physical health condition are observed, licensee shall ensure	1 2 3 4 5 6 7	Administrator agrees to submit facility protocol outlining how residents are observed for changes, how those changes are documented and communicated to resident's responsible party and doctor and who determines that a resident should receive medical intervention by POC due date 3/6/21.
	8 9 10 11 12 13 14	that such changes are documented & brought to the attention of the resident's physician & responsible person, if any. Requirement isn't met as evidenced by: Based on interviews, licensee didn't ensure that resident's doctor was notified of their Covid positive status by the facility which poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14

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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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