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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803751
Report Date: 12/12/2024
Date Signed: 12/12/2024 06:51:03 PM

Document Has Been Signed on 12/12/2024 06:51 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:
496803751
ADMINISTRATOR/
DIRECTOR:		MAY,JERALYNFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY: 82CENSUS: 46DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Jeralyn May, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:05 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Jeralyn May.

At approximately 10:00am LPA toured the building and grounds. LPA toured kitchen. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Some food items observed were not covered or not labeled with date of opening: chocolate mousse, cakes, and dishes of fruit, gallon of milk and white food item that looked like mashed potatoes or riced cauliflower (deficiency cited, see 809D). LPA observed box of lettuce and lettuce actively being used to prepare salads to have black wilted leaf tips and/or stalks. Some the the leaf tips were both black and had a white fuzzy substance present (deficiency cited, see 809D). LPA observed freezer temperature log to be missing temperature recordings for two AM shifts and one [1] PM shift, and the refrigerator temperature log was missing temperature recordings for three [3] PM shifts and five [5] AM shifts.

All bedrooms in Memory Care buildings 1 and 2 were equipped with lighting, night stand, and chest of drawers. All bedrooms viewed in Assisted Living were also equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Residents' main shower/bathroom in Memory Care building 1 had required grab bar but did not have non-skid mat or strips present. Water temperature in sink accessible to residents in care measured at 116.6 degrees F in the outer dining room kitchen sink and 114.2 degrees F in the internal dining room sink, 108.7 degrees F in room 302, 107.2 degrees F in room 101, and 107.4 degrees F in room G, all which are within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 3/12/24. Smoke/Carbon Monoxide detectors located throughout the facility and serviced by a vendor, last serviced on 11/19/24. Facility’s last quarterly disaster drills were conducted on 10/2024.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HEALDSBURG SENIOR LIVING COMMUNITY
FACILITY NUMBER: 496803751
VISIT DATE: 12/12/2024
NARRATIVE
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Continued from 809...

LPA observed the pendant call button system to not be properly working. LPA interviewed resident in room 101 (R2). LPA pressed resident's pendant at 11:34am. Staff (S1) arrived at 11:42am to room 101 to take the resident down for lunch. LPA asked caregiver if they were here to answer the pendant call, they said no, and explained that they did not receive a page and were here to take the resident to lunch. Care giver then proceeded to wheel the resident down to the dining area. Admin was approaching down the hall as S1 was leaving. LPA advised Admin of pendant alarm not working. LPA confirmed with Admin that pendant flashed red when LPA pressed it. The pendants flash red when they are activated then turn green once reset/answered by staff. The staff are to receive a page when the pendant is pushed and the call is also logged on the pendant/call button computer. Admin and LPA went to review computer call button log and there was no call showing from room 101. Admin went to resident in dining hall and pressed resident's pendant, S1 was present as well. Once again S1 did not receive the page and the call request was not logged on the call button computer log (deficiency cited, see 809D).

At approximately 1:00pm LPA conducted a spot check of medication and medication records in Memory Care building 2. Medication is centrally stored in a locked cart in a locked room. LPA observed Olanzapine 2.5 mg prescription filled on 12/7/24 for R1 to be missing from the Centrally Stored Medication Log (CSML) (deficiency cited, see 809D).



LPA conducted a review of 6 resident records. LPA conducted review of 5 staff records. S3, S4, S5 and S6 did not have current CPR on file (deficiency cited, see 809D). S4 and S6 do not have complete required training on file (deficiency cited, see 809D)

Jeralyn May Administrator Certificate 7036260740 expires 11/14/25. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report and Liability Insurance

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 Admin. 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: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
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Page: 2 of 7
Document Has Been Signed on 12/12/2024 06:51 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/12/2024 at 05:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and record review, the licensee did not comply with the section cited above in that an entry for an Olanzapine 2.5 mg prescription filled on 12/7/24 for R1 was missing from the Centrally Stored Medication Log which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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2
3
4
Facility to submit LIC9098 self-certifying all medications for all residents is listed on their respective Centrally Stored Medication logs .
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
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4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


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Document Has Been Signed on 12/12/2024 06:51 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/12/2024 at 05:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(i)(1)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that pendant system not repsonding correctly to calls/pages when R2's pendant pressed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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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 10 day pendant call button system log to CCL showing all calls answered within a timely manner by plan of correction due date. Admin agrees that within 15 minutes can be defined as within a timely manner.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S3, S4, S5 and S6 did not have current CPR on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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Facility to submit picture of current CPR cards for S3, S4, S5 and S6 by plan of correction due date.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2024 06:51 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/12/2024 at 05:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above inthat S4 and S6 do not have complete required training on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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Facility to submit proof of completed required orientation training for S4 and S6 by plan of correction due date.

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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 12/12/2024 06:51 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/12/2024 at 05:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed box of lettuce and lettuce actively being used to prepare salads to have black wilted leaf tips and/or stalks. Some the the leaf tips were both black and had a white fuzzy substance present, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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2
3
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Facility to submit LIC9098 self-certification of proper food service training completed by all food service personnel by plan of correction due date.
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that Some food items observed were not covered or not labeled with date of opening: chocolate mousse, cakes, and dishes of fruit, gallon of milk and white food item that looked like mashed potatoes or riced cauliflower, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
1
2
3
4
Facility to submit LIC9098 self-certification of proper food service training completed by all food service personnel by plan of correction due date.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


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