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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803751
Report Date: 10/30/2025
Date Signed: 10/30/2025 11:15:15 AM

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
08/08/2025 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20250808144348
FACILITY NAME:HEALDSBURG SENIOR LIVING COMMUNITYFACILITY NUMBER:
496803751
ADMINISTRATOR:RODRIGUEZ, BRANDEEFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 40DATE:
10/30/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Brandee Rodriguez, Executive DirectorTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Facility staff did not follow residents care plan
Facility staff did not meet residents care needs
INVESTIGATION FINDINGS:
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At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegations and met with facility Administrator Brandee Rodriguez.

During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents.

Complaint alleges staff did not follow the resident’s care plan and that the staff did not meet the resident’s care needs. The facility has five (5) levels of care for Assisted Living with level one (1) being the least amount of care and level five (5) being the highest level of care. The facility conducted Resident Assessments of resident R1 on 12/1/2024 and on 5/14/2025. Both assessments of R1 stated that R1 requires level five (5) care. The Needs and Services Plans (NSP), reflective of the previously noted assessments, states that R1 requires “Total Assist” for Bathing, Grooming, Dressing and Ambulation.
Continued on 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
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 6
Control Number 21-AS-20250808144348
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: 10/30/2025
NARRATIVE
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...Continued from 9099

The two (2) NSPs also state that for Toileting and Transfers R1 will require a “two (2) person assist”. During review of facility staff schedules LPA observed that only one (1) Caregiver (CG) was assigned to the entire Assisted Living unit. The facility currently has a probationary license. As part of the Stipulation and Waiver, and Order dated 6/30/2022, the License understands that facility staff must be hired in numbers necessary to meet the needs of the residents. To that extent, each Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Medication Technician (MT) will not be a direct care staff but may provide support when not distributing medication. LPA reviewed the facility call system response logs from 7/1/2025 to 8/7/225 and observed that within this time frame there were five (5) instances where R1 requested assistance, and the response time exceeded fifteen (15) minutes. Additionally, there is video showing R1 being moved to a wheelchair positioned at the base of the bed in front of the television at approximately 5:40 AM. Resident R1 was not moved back into their bed until approximately 1:32 PM when the video shows a single (1) staff member moving R1 into bed although their NSP states that R1 requires a two (2) person assist for transfers. Based on LPA’s observations 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. The facility was cited for the same deficiency on 11/19/2024, 5/6/2025 and 7/24/2025. As this repeat deficiency occurred within one (1) year of the previous citations, a Civil Penalty of $1000.00 will be assessed.

Exit interview conducted. Copy of LIC-9099, LIC-9099-C, LIC-9099D, Plan of Corrections, LIC-421IM and Appeal Rights discussed and provided to Executive Director Rodriguez. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
08/08/2025 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20250808144348

FACILITY NAME:HEALDSBURG SENIOR LIVING COMMUNITYFACILITY NUMBER:
496803751
ADMINISTRATOR:RODRIGUEZ, BRANDEEFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 40DATE:
10/30/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Brandee Rodriguez, Executive DirectorTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Facility staff do not have adequate training
Unlawful Eviction
INVESTIGATION FINDINGS:
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At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegations and met with facility Administrator Brandee Rodriguez.

During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents.

Complaint alleges that the facility staff do not have adequate training. LPA reviewed personnel files for four (4) Caregivers primarily assigned to the Assisted Living (AL) section of the facility. LPA observed that four (4) of four (4) Caregivers had completed their initial training when first hired. LPA further observed that the same four (4) Caregivers have completed 75% of their required annual twenty (20) hours of training with the remaining portion of training already scheduled.

Continued on 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
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 6
Control Number 21-AS-20250808144348
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: 10/30/2025
NARRATIVE
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...Continued from 9099

Additionally, LPA observed that the same four (4) Caregivers were current and have completed the required four (4) hours of additional monthly training as part of the Stipulation and Waiver, and Order dated 6/30/2022. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Complaint alleges the facility unlawfully evicted resident R1. Witness reported that the facility was requiring resident R1 to move from Assisted Living (AL) to Memory Care (MC) due to a change in R1’s cognitive function. The witness further stated that they asked the facility for proof, in writing, of the cognitive change as diagnosed by a licensed medical professional. Resident R1’s Residence and Care Agreement, section G Change of Level of Care states, “If we determine that you need a different level of care than that which you are currently receiving, we will provide you and your responsible person, if applicable, with written notice of the change.” The facility did not provide proof of any cognitive change for R1. During interviews facility staff members S2 and S3 stated that no written notice was given as they were not requiring that resident R1 move to Memory Care. Staff members S2 and S3 stated that the move would be voluntary. Neither the facility nor the witness was able to provide any documentation stating that the facility was requiring that resident R1 be moved to Memory Care. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. Copy of report discussed and provided to Executive Director Rodriguez. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20250808144348
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: 10/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2025
Section Cited
HSC
1569.269(a)(c)
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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. This requirement was not met by licensee as evidenced by
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Licensee or Administrator will submit a plan to sufficiently staff the facility per resident care needs to CCL by POC due date of 10/31/2025. Facility to submit to CCL updated LIC500 with staff schedules showing adequate staffing by no later than 11/7/2025.
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Based on record review and interviews the licensee did not comply with the section cited above in that staffing in AL is not sufficient per resident care needs including but not limited to requiring a two person assist, which poses a immediate health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6