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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803751
Report Date: 12/08/2022
Date Signed: 12/08/2022 03:42:56 PM


Document Has Been Signed on 12/08/2022 03:42 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:ALVAREZ, CINTHYAFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 40DATE:
12/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Administrator, Cinthya GaminoTIME COMPLETED:
03:52 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Prelicensing inspection and met with Administrator, Cinthya Gamino arrived later.

A Change of Ownership application is in process with the Department that includes three buildings, one that houses Assisted Living residents and two separate buildings which are designated for residents with dementia. There are currently residents in care. Applicant is have a fourth building built that is not a part of the current license or application. LPA communicated to the Administrator during this inspection that once the fourth building is completed and ready for additional residents, the Licensee will need to apply for a Capacity Increase and the building will need a fire clearance and an inspection by CCL prior to the building being used for residents.

LPA initiated a walk through of the facility around 10:00am which included various resident rooms in assisted living and memory care, medication rooms, activity rooms, common areas, kitchen, dining room and outside areas. LPA observed the following: Facility continues to screen visitors and staff at the front desk per CCL guidance and has Covid-19 posters throughout common areas. Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms are furnished appropriately and bathrooms have required grab bars. Water temperature in sampling of resident rooms were 105, 105 and 106 degrees F and which are within regulation. Kitchen has sufficient storage for perishable and non-perishable foods. File storage is locked to maintain confidentiality. Medication is centrally stored and locked in medication rooms in assisted living and memory care. Toxins are locked in utility closets and housekeeping carts.

Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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 2


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: 12/08/2022
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Continued from LIC809

The construction area of the facility is fenced to ensure resident safety. Facility has required Complaint Posters as well as Resident Rights posters. The area designated for Family and Resident Council notices is no longer clearly identified so LPA requested that those areas be clearly marked again. Activity posters were observed in each unit.

Fire extinguishers were last serviced April 2022. Facility has a vendor who comes in routinely to test the fire system and the most recent service was conducted November 2022. Per Administrator the fire system also includes carbon monoxide detectors. Facility has a call bell system and each resident room and public restroom has a call bell. Memory care has functional delayed egresses.

Based on knowledge of current Administrator, Component III is waived.

Administrator provided LPA with their most recent Emergency Disaster Plan.

LPA will notify the Centralized Application Bureau so they may move forward with Licensure.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2