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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803751
Report Date: 05/06/2025
Date Signed: 05/06/2025 05:18:13 PM

Document Has Been Signed on 05/06/2025 05:18 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: 40DATE:
05/06/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Brandee Rodriguez, Acting AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analysts (LPAs) Christi Coppo and Robert Frank arrived unannounced to conduct a Legal Non-Compliance Case Management inspection.

The following items were indicated as deficient in the most recent audit dated 1/31/2025:
  • Dementia Care. No monthly activity calendar or daily events.

The following items were indicated as deficient in the most recent audit dated 2/27/2025:
  • Dining. Food products with no cover or expiration date.
  • Dementia Care. No monthly activity calendar or daily events.

The following items were indicated as deficient in the most recent audit dated 5/2/2025:
  • Medication Management. Med cart two (2) has discontinued medications from 4/21/2025.
  • Dementia Care. In Memory Care two (2) curling iron found under sink and small cleaning spray found on night stand.
  • Dementia Care. Scissors stored on the outside of the Med cart in Memory Care Two (2).

These Deficiencies will be cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code.

Continued on 809-C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/06/2025
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...Continued from 809

The following items are some of the requirements required per the current Stipulation and Waiver and Order (dated 6/30/2022) in place for the facility:
  1. Facility shall provide a minimum of four (4) hours of training monthly to direct care staff and managers. All staff that provide medication administration must receive one additional hour of training every month.
  2. Pacifica shall perform quarterly audits of medication inventory and if errors are found, a plan of correction for each error found shall be included with the applicable audit report
  3. Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Med Tech will not be a direct care staff, but may provide support when not distributing medication.
  4. Facility call system and delayed egress shall at all times be fully functional.

As it pertains to item #3, LPAs observed one (1) Caregiver (CG) S4, present in Memory Care building Two (MC2). LPAs reviewed facility staff schedule for 5/6/2025 and found that S2 was the only CG scheduled for the Day shift. LPAs further observed that there was only one (1) CG, S5 scheduled for the PM shift. However, there is one resident identified as being a 2-person assist in MC2. Therefore, facility was found to be deficient in requirement required as part of the current Stipulation and Waiver and Order in place for the facility. LPAs reviewed staff schedule for 5/6/25 with Tiffany Leos, Resident Care Coordinator (RCC) and Admin and pointed out the staffing deficiency. This deficiency will be cited in Complaint #21-AS-20250501120816.

On 3/26/25 Healdsburg Senior Living (HSL) representatives met with CCL at the Santa Rosa Regional Office. During this meeting items were discussed pertaining to the Stipulation and Waiver and Order dated July 18, 2022. One item identified as needing to be provided to CCL was: Facility will provide a list of all individuals who have acted as the Liaison since the effective date of the Stipulation and Order and how they ensured facility was meeting the mandate as identified in the Stipulation and Order. HSL submitted the list of individuals. However, during today’s visit, Administrator informed LPAs that current designated liaison, Karen Enciso, Regional Director of Operations (RDO) will no longer be with the company as of 5/9/25, at the latest.

Continued on 809-C(2)

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/06/2025 05:18 PM - It Cannot Be Edited


Created By: Robert Frank On 05/06/2025 at 12:51 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: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2025
Section Cited
CCR
87465(i)

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Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor...established procedures or which are otherwise to be disposed of shall be destroyed ...This requirement not met by licensee as evidenced by:
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Licensee or Administrator will provide proof to CCL that all Medicine Technicians have taken Medication Destruction training in 2025 by the POC due date of 5/27/2025.
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Based on LPAs review of Monthly Quality Assurance Audit per stipulation dated 5/1/2025, Licensee did not ensure discontinued medications were destroyed, which poses an potential health, safety or personal rights risk to persons in care.
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Type B
05/27/2025
Section Cited
CCR87219(f)

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In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order... This requirement not met by licensee as evidenced by:
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Licensee or Administrator will provide the monthly activity calendar for May, 2025. Licensee will further provide an LIC 9098 Proof of Corrections self certifying that going forward Activity Calendars will be created and posted for residents by POC due date of 5/27/2025.
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Based on LPAs review of Monthly Quality Assurance Audit per stipulation dated 1/31/2025 & 2/26/2025, Licensee did not create a monthly activity calendar for Memory Care, which poses an potential 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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 05/06/2025 05:18 PM - It Cannot Be Edited


Created By: Robert Frank On 05/06/2025 at 01:55 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: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2025
Section Cited
CCR
87309(a)

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Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger... This requirement not met by licensee as evidenced by:
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Licensee or Administrator will provide an LIC 9098 Proof of Corrections self certifying that CCR Regulation 87309(a) was reviewed with all Memory Care staff by POC due date of 5/7/2025.
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Based on LPAs review of Monthly Quality Assurance Audit per stipulation dated 5/2/2025 in Dementia Care, scissors were stored on the outside of the medicine care in Memory Care building two (2) which poses an 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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 05/06/2025 05:18 PM - It Cannot Be Edited


Created By: Robert Frank On 05/06/2025 at 02:12 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: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2025
Section Cited
CCR
87555(b)(23)

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All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food...shall be stored in covered containers at appropriate temperatures. This requirement not met by licensee as evidenced by:
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Licensee or Administrator will provide an LIC 9098 Proof of Corrections self certifying that proper food service training is completed by all food service personnel by POC due date of 5/27/2025.
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Based on LPAs review of Monthly Quality Assurance Audit per stipulation dated 2/27/2025, food products were not covered or marked with an expiration date, which poses an 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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
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: 05/06/2025
NARRATIVE
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...Continued from 809-C

Therefore, LPAs are requesting that HSL submit a letter to CCL indicating the name of the new liaison and how HSL will ensure facility will meet the mandate as identified in the Stipulation and Order by end of business day 5/9/2025.

Per the stipulation, waiver and order page 3, line items 25-27 and page 4, line items 1-11 Facility shall provide a minimum of four (4) hours of training monthly to direct care staff and managers. Staff, S6, S7, S8, S9,S10 and S11 were all identified as having stipulation training completed per respective Monthly Quality Assurance Audit. Per LPA and Administrator review, documentation of required stipulation training does not indicate the number of hours for each session completed. Therefore, LPAs cannot determine the number of hours completed for the monthly training required by the stipulation.

Per page four [4] line item 20 and page five [5], line items 5, 6, and 7 of the Stipulation and Order dated July 18, 2022, HSL is to submit a monthly LIC500 along with the census of each unit and two person assists identified. CCL received LIC500s for the months of January, February, Mar, and April. CCL received resident roster identifying resident requiring 2-person assist for the months of March and April, but did not receive a resident roster identifying residents requiring 2-person assist for the months of January and February.

Further of audits dated 1/31/2025, 2/27/2025, 3/31/2025 and 5/2/2025 showed some minor instances of non-compliance however the instances were not significant or frequent enough to warrant a health and safety concern.

LPAs discussed and reviewed stipulation with the new Administrator Brandee Rodriguez and provided Administrator with a copy of the stipulation.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.



Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Administrator Rodriguez. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
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