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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803751
Report Date: 05/06/2025
Date Signed: 05/06/2025 05:37:42 PM

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
05/01/2025 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20250501120816
FACILITY NAME:HEALDSBURG SENIOR LIVING COMMUNITYFACILITY NUMBER:
496803751
ADMINISTRATOR:MAY,JERALYNFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 40DATE:
05/06/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brandee Rodriguez, Acting AdministratorTIME COMPLETED:
05:50 PM
ALLEGATION(S):
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Facility does not have adequate staffing to meet the needs of residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Robert Frank and Christi Coppo arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegation and met with facility Administrator Brandee Rodriguez.

Complaint alleges facility does not have adequate staffing to meet the needs of residents in care. Complainant states that only one direct care provider is scheduled per shift, but the care needs of residents require at least two staff be present, as some residents require a two-person assist.
During investigation, LPAs reviewed staff schedule for 5/6/25. LPAs observed that staffing for Memory Care buildings 1 and 2 (MC1)(MC2) is such that there are two caregivers scheduled with one Med Tech present. Review of schedule indicates that lunches are not scheduled such that they are staggered to ensure each Memory Care unit has two staff present at all times.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20250501120816
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: 05/06/2025
NARRATIVE
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...Continued from 9099
Additionally, facility is under Stipulation and Order and Waiver (Stip) as of 6/30/22. As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, page four (4), line items 26-27 and page five (5), line items 1-5, each Memory Care unit and Assisted Living unit will be staffed independently such that the units do not share direct care staff. The medication tech will not be a direct care staff but may provide support/backup when not distributing medication…and staff breaks and lunch shall be staggered so there is adequate staff coverage.

LPAs review of staffing schedule for 5/6/25 shows that there are two (2) direct care staff scheduled for day shift for MC1, with one Med Tech present. However, both the Med Tech and one of the direct care staff are scheduled to take lunch at the same time, 10:00am, leaving only one direct care staff on duty during the lunch break. LPA review of staffing schedule for 5/6/25 shows that there is one (1) direct care staff scheduled for day shift for MC2, with one Med Tech present. However, both the Med Tech and the one (1) direct care staff are scheduled to take lunch at the same time, 10:30am.

During investigation, LPAs reviewed resident roster indicating which residents require a two-person assist. Review of roster indicates there are three (3) residents (R1, R2, and R3) in MC1 that require a two-person assist and one (1) resident (R4) in MC2 that requires a two-person assist. So, based on the care needs of residents, facility is found to be out of compliance with the Stip.

Based on LPAs’ 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.

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-9099D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Administrator Rodriguez. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250501120816
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: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2025
Section Cited
HSC
1569.269(a)(6)
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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.
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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 5/7/2025. Facility to submit to CCL updated LIC500 showing adequate staffing by no later than 5/28/2025.
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This requirement was not met by licensee as evidenced by: Based on LPA and Admin record review, the licensee did not comply with the section cited above in that staffing in MC1 and MC2 is not sufficient per resident care needs 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: 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
LIC9099 (FAS) - (06/04)
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