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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803751
Report Date: 10/16/2024
Date Signed: 10/16/2024 12:49:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20240709101931
FACILITY NAME:HEALDSBURG SENIOR LIVING COMMUNITYFACILITY NUMBER:
496803751
ADMINISTRATOR:GAMINO, CINTHYAFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: ZIP CODE:
95448
CAPACITY:82CENSUS: 46DATE:
10/16/2024
UNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Jeralyn May, AdministratorTIME COMPLETED:
01:02 PM
ALLEGATION(S):
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Licensee does not provide adequate or proper training
Licensee does not ensure adequate staffing
Personal Rights
Residents needs are not being met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with Jeralyn May, Administrator.

Complaint alleges licensee does not provide adequate or proper training. Complainant states housekeeping personnel are doing caregiving duties without training. During investigation, seven [7] out of seven [7] staff interviewed state that housekeeping personnel are performing caregiving duties. On 7/12/2024, LPA observed staff identified as housekeeping to be working and providing care to residents in Memory Care building #1 (MC1). During investigation, LPA reviewed training records for seven [7] staff. Seven [7] out of seven [7] staff did not have current training or did not have the required amount of current training hours completed. Based on LPA’s observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
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 7
Control Number 21-AS-20240709101931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 496803751
VISIT DATE: 10/16/2024
NARRATIVE
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continued from 9099...

Complaint alleges licensee does not ensure adequate staffing. Complainant states not enough staff to properly transfer residents requiring assistance. Complaint alleges Personal rights. Complainant states residents are not allowed to go to their bedrooms and residents remain in wheelchairs for extended periods of time. During investigation, LPA interviewed seven [7] staff. Five [5] out of seven [7] employees state they need help and don’t have enough staff to meet residents' care needs. Additionally, seven [7] out of seven [7] staff say they do not get breaks because there is not enough staff to cover. Five [5] out of seven [7] staff say at times, there is only one person working in MC1. Only one staff being present could be due to staff lunch or as some staff reported, in the most recent summer months only one person was actually working in MC1 per shift. Additionally, one [1] out of one [1] witness states that there is sometimes only 1 person in MC1 during a shift, but definitely only one during lunches. Three [3] out of seven [7] staff and one [1] out of one [1] witness state that the residents remain in their wheelchairs for extended period of time due to not having enough staff to transfer from wheelchair to the recliners in the living room of MC1.

During investigation, LPA reviewed staff schedule. Staff schedule shows that no more than 2 people are assigned to MC1 at any given time, not including coverage during staff lunches. However, LPA review of residents’ physician reports and care plans of the ten [10] residents residing in MC1 shows that:

· 9 Need a total assist with Bathing,

· 7 Need a total assist with Grooming

· 10 Need a total assist with Dressing

· 10 Need a total assist with Toileting

· 4 Need a total assist with Transfers

· 10 Need total assist with Medications

· 7 Are identified as a fall risk

Continued on 9099C(2)...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 21-AS-20240709101931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 496803751
VISIT DATE: 10/16/2024
NARRATIVE
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continued from 9099C...

· 1 Need a stand-by assist with Bathing,

· 3 Need a stand-by with Grooming

· 4 Need a stand-by with Transfers

· 4 residents in MC1 require a 2 person assist as indicated by their care plans and as indicated by staff.

Based on LPA’s observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Complaint alleges resident needs are not being met. During investigation, Administrator advised the method by which residents alert staff that they need help or require assistance is through a pendant call button system. Each resident is assigned a pendant. When a resident needs help or assistance with a care need, they push the button on their pendant in order to alert staff to their need. LPA review of pendant log shows that between 6/30/24 and 7/2/24 residents pushed their pendant call button 36 times. Of those 36 times, the wait times until someone arrived to help were:

· 8 waited at least 15 minutes,

· 11 waited at least 30 minutes, and

· 16 either never got a response or there was an error in the pendant log system.

LPA review of pendant log shows that between 9/1/2024 and 9/27/2024 residents pushed their pendant call button 621 times. Of those 621 times, the wait times until someone arrived to help were:

· 94 waited 15 minutes or more,

· 56 waited 30 minutes or more,

Continued on 9099C(3)...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 21-AS-20240709101931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 496803751
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2024
Section Cited
HSC
1569.625(b)(2)
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§1569.625 Staff training... (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...

This requirement was not met by licensee as evidenced by:
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Facility to ensure all staff are current in their annual training. Facility to submit to CCL currrent annual training records for all care staff and Medication Technicians showing current training completed by plan of correction due date.
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Based on LPA record review, the licensee did not comply with the section cited above in that seven out of seven staff files reviewed, staff did not have the required hours of annual training completed, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
11/06/2024
Section Cited
HSC
1569.269(a)(6)
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§1569.269 Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Facility to ensure that pendant call button system is in good repair and operational, staff is sufficient to answer calls in a timely manner, when residents are in need of assistance. Facility to submit three week pendant call button system log to CCL showing all calls answered
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This requirement was not met by licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, the licensee did not comply with the section cited above in that between 9/1/2024 and 9/27/2024 residents pushed their pendant call button at least 621 times. Of those 621 times at least 126 either never got a response or there was an error in the pendant log system, which poses a potential health, safety or personal rights risk to persons in care.
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within a timely manner by plan of correction due date. Admin agrees that within 15 minutes can be defined as within a timely manner.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 21-AS-20240709101931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 496803751
VISIT DATE: 10/16/2024
NARRATIVE
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Continued from 9099C(2)...

· 20 waited at least 1 hour,

· 7 waited more at least 2 hours,

· 3 waited at least 3 hours,

· 1 waited at least 5 hours,

· 1 waited at least 6 hours, and

· 126 either never got a response or there was an error in the pendant log system.

Additionally, the pendant call button/pull cord was pushed in Memory Care #1 bathroom or rear door a total of 6 times, where the wait times show as:

· 1 for 21 hours,

· 1 for 14 hours,

· 1 for 7 hours,

· 2 for 5 hours, and

· 1 time either they never got a response or there was an error in the pendant log system.

During investigation, on 7/12/2024 at approximately 10:30am, LPA entered the room of a resident (R6) for the purposes of conducting an interview. Resident informed LPA she has been pressing her pendant for the past 45 minutes and no one has come. LPA then pushed resident's pendant and set the stopwatch timer. LPA observed a caregiver to arrive to answer the pendant 24 minutes after LPA pushed the pendant. During investigation, on 9/27/24 LPA interviewed resident (R4). While interviewing R4, LPA asked to push their pendant in order to confirm caregivers’ response time. LPA waited for 32 minutes. LPA did not observe staff to address the pendant alert while present in the room.

Continued on 9099C(4)...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 21-AS-20240709101931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 496803751
VISIT DATE: 10/16/2024
NARRATIVE
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continued from 9099C(3)

Based on LPA’s observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 21-AS-20240709101931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 496803751
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2024
Section Cited
CCR
87705(c)(4)
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87705 Care of Persons with Dementia (c) (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and heakth care needs. as identified in their current appraisal/care plan. This requirement was not met by licensee as evidenced by:
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Facility to submit to CCL updated LIC500 showing adequate staffing in Memory Care building #1, in numbers at least as much as outlined in the Stipulation and Waiver and Order dated 6/30/2022 or greater, and in numbers that ensure meeting each resident’s physical, social, emotional, safety and
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Based on LPA interviews and record review, facility does not have adequate number of direct care staff In Memory Care building #1 to support each resident’s physical, social, emotional, safety, and health care needs as identified in their current appraisal/care plan and/or physician's report, which poses a potential health, safety or personal rights risk to persons in care.
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health care needs as identified in their current appraisal/care plan and/or physician's report. Additionally, facility will provide written statement indicating how they will secure adequate staffing. Plan to address staffing coverage when staff is at lunch or on break, or when scheduled staff is not present at the facility.
Type B
10/30/2024
Section Cited
CCR
87468.2(a)(6)
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87468.2 Additional Personal Rights...(a) In addition to the rights listed in Section 87468.1... residents... shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility. This requirement was not met by licensee as evidenced by:
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Facility to submit to CCL updated LIC500 showing adequate staffing in Memory Care building #1, in numbers at least as much as outlined in the Stipulation and Waiver and Order dated 6/30/2022 or greater, and in numbers that ensure meeting each resident’s physical, social, emotional, safety and
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Based on LPA interviews and record review, facility does not have adequate number of direct care staff In Memory Care building #1 to support each resident’s physical, social, emotional, safety, and health care needs as identified in their current appraisal/care plan and/or physician's report, such that they can make choices concerning their daily lives in the facility, which poses a potential health, safety or personal rights risk to persons in care.
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health care needs as identified in their current appraisal/care plan and/or physician's report. Additionally, facility will provide written statement indicating how they will secure adequate staffing. Plan to address staffing coverage when staff is at lunch or on break, or when scheduled staff is not present at the facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7