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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801635
Report Date: 03/05/2021
Date Signed: 03/05/2021 03:10:13 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
10/01/2020 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20201001092715
FACILITY NAME:HEALDSBURG SENIOR LIVING COMMUNITYFACILITY NUMBER:
496801635
ADMINISTRATOR:ROB MATTHEWSFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: DATE:
03/05/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Tracey Mease and Resident Care Coordinator, Tru CoinerTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility failed to serve good quality food
Facility failed to keep the facility clean
Facility failed to ensure medications were inaccessible to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Willis 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 failed to keep the facility clean - Complaint alleges that resident apartments are not cleaned according to the agreed cleaning schedule and there have instances in which fecal matter was observed on the toilet seat, dirty gloves left on the floor, used toilet paper left on the floor and the toilet left un-flushed. During interviews of responsible parties, LPA learned that some have observed fecal matter on resident's personal belongings and on the toilet.
Continued on LIC9099
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20201001092715
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

Others observed floors being dirty and rugs not being vacuumed. Interviews also revealed that some families clean resident's rooms while visiting and in at least one instance a Private Companion was hired to perform cleaning tasks that were not being completed. Per interviews with facility staff, resident rooms are generally cleaned once per week. If more frequent cleaning is required in between the weekly maintenance cleaning, such as a soiled toilet or a spill, the caregiver assisting the resident would be responsible for the clean-up. Interviews identified that not all caregivers will clean as required and may leave it for housekeeping.

Facility failed to serve good quality food - Complaint alleges that meals listed on the menu are frequently replaced without notice and food is of low quality. Based on multiple interviews, and a review of picture provided LPA learned that in approximately the last year meals have not always been nutritionally balanced and at times did not include a protein or vegetable. Interviewees described meat as fatty, dry and tough and in one instance, the meat had become discolored.

Facility failed to ensure medications were inaccessible to residents – Complaint alleges that a cup of medication was left in R1's room that did not belong to them. Interview of involved staff confirmed that medication not belonging to the resident was observed and removed from R1's room by the staff member. Staff interview indicated that Medication Technician's will leave medication in resident's room because residents don't like them "hovering".

Based on evidence obtained during the investigation, the allegations that Facility failed to serve good quality food,
Facility failed to keep the facility clean and Facility failed to ensure medications were inaccessible to residents 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 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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/01/2020 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20201001092715

FACILITY NAME:HEALDSBURG SENIOR LIVING COMMUNITYFACILITY NUMBER:
496801635
ADMINISTRATOR:ROB MATTHEWSFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: DATE:
03/05/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Tracey Mease and Resident Care Coordinator, Tru CoinerTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility failed to safeguard resident's property
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 done remotely 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 and reviewed pictures and other records.

Complaint alleges that facility lost articles of resident’s clothing and that a topical cream was taken from their room. Interviews revealed that clothing items of some residents have gone missing or residents were observed wearing clothes that did not belong to them. Facility staff indicated that resident's laundry is done individually and not mixed with the clothing of other residents.
A finding that the complaint allegation that facility failed to safeguard resident's property was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred. We have therefore dismissed the complaint.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20201001092715
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
87465(h)(2)
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87465 Incidental Medical and Dental Care - The following requirements shall apply to medications which are centrally stored:
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as
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Administrator agrees to submit a training schedule showing that all staff who assist with the self administration of medication will be trained per regulation by POC due date, 3/6/2021. Proof of training for noted staff must be provided to CCL no later than 3/19/2021.
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evidenced by: Based on interviews the licensee did not ensure that centrally stored medication was left inaccessible to residents which poses an immediate risk to the health and safety of residents in care.
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Type A
03/06/2021
Section Cited
CCR
87555(a)
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87555 General Food Service Requirement (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents & shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Administrator agrees to submit facility protocol outlining how often food is delivered to residents and how it is assessed for quality by POC due date, 3/6/2021. Additionally, proof of training for all kitchen staff must be provided to CCL by 3/19/2021.
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This requirement is not met as evidenced by: Based on multiple interviews licensee did not ensure food quality indicating that food being served is fatty, dry, tough and meals are not well rounded which is a potential 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20201001092715
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 B
03/12/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not been met as evidenced by: Based on multiple interviews the licensee
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Administrator agrees to submit written protocols outlining the expectation of all staff regarding cleanliness of the facility including but not limited to, who is responsible for cleaning the bathroom on an as needed basis and what items are included in the weekly general cleaning by POC due date 3/12/2021. Proof of training for all caregivers and house-
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did not ensure facility was clean and sanitary because witnesses observed feces on toilets, dirty floors and rugs needing to be vacuumed which poses a potential risk to health and safety of residents in care.
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keeping staff on this protocol is due to CCL no later than 3/19/2021.
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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
LIC9099 (FAS) - (06/04)
Page: 5 of 5