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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803751
Report Date: 11/18/2025
Date Signed: 11/18/2025 10:06:18 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: 39DATE:
11/18/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Shauna Burton, Back Up AdministratorTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Due to lack of staff resident sustained a pressure injury
INVESTIGATION FINDINGS:
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At approximately 8:50 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegations and met with facility back up Administrator Shauna Burton.

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

Complaint alleges that due to lack of staff resident sustained a pressure injury. 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.

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

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
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 4
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: 11/18/2025
NARRATIVE
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...Continued from 9099

The Needs and Services Plans (NSP), reflective of the previously noted assessments, states that R1 requires “Total Assist” for Bathing, Grooming, Dressing and Ambulation. 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 facility charting notes for resident R1 from 4/4/2025 to 7/23/2025. From 4/4/2025 to 4/30/2025 there are four (4) entries. The April entries do not state that R1 is being turned or repositioned. There is one (1) charting note entry for May. The single May entry does not state that R1 is being turned or repositioned. There are twenty-one (21) charting note entries for June for the dates of 6/1/2025 to 6/25/2025. On 6/6/2025 charting notes state, “We noticed the beginning of a peel on the resident bottom. We put barrier cream. RSD has already been notified family and doctor. Please reposition (them) and continue to put barrier cream. Will continue to monitor”. Charting note entries on 6/6/2025 & 6/7/2025 note that barrier cream has been applied. Charting note entry on 6/11/2025 state, “Nurse from Advanced Home health care to assess resident for wound care on their coccyx area. Nurse stated their wound is a Stage 2. Relative/POA will be bringing extra pillows to assist with repositioning them. Care staff are to support repositioning appx every 2 hours or as needed.” Later on 6/11/2025 there are two (2) additional charting note entries that state resident was repositioned every two (2) hours. On 6/12/2025 a charting note entry states that R1 was repositioned every two (2) hours. From 6/13/2025 to 7/23/2025 there were no further charting note entries related to repositioning R1 every two (2) hours. 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.

Continued on 9099-C2...

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

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 11/18/2025
NARRATIVE
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...Continued from 9099-C

Video shows R1 was moved back into their bed at approximately 1:32 PM. During review of facility staff schedules LPA observed that one (1) Caregiver (CG) was assigned to the entire Assisted Living unit during the thirty (30) days preceding R1’s being diagnosed as a Stage 2 wound. Based on LPA’s 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.

Exit interview conducted. Copy of LIC-9099, LIC-9099C, LIC-9099C2 LIC-9099D, LIC-811 Confidential Names, Plan of Corrections and Appeal Rights discussed and provided to back up Administrator Burton. Signature on form confirms receipt of documents.

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

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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: 11/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/19/2025
Section Cited
CCR
87411(a)
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87411Personnel Requirements-General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff...
This requirement is not met as evidenced by:
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Licensee to self certify that the facility will provide sufficient staff to meet the residents needs. Additionally, the Licensee will submit a plan on how the facility's Caregivers will be informed that residents need to be repositioned and how repositioning will be confirmed.
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Based on interviews and record review, the licensee did not comply with the section cited above in that lack of sufficient staffing prevented resident R1 to be repositioned which caused resident R1 to develop a stage 2 pressure wound which poses an immediate health, safety or personal rights risk to persons in care.
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Both items will be submitted to Community Care Licensing by POC due date of 11/19/2025.
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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: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4