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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803751
Report Date: 11/19/2024
Date Signed: 11/19/2024 06:02:27 PM

Document Has Been Signed on 11/19/2024 06:02 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: DATE:
11/19/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:06 PM
MET WITH:Tiffany, Director of Resident Care ServicesTIME VISIT/
INSPECTION COMPLETED:
06:17 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Legal Non-Compliance Case Management inspection and met with Resident Services Director Tiffany Roas (RSD). Admin not present but was available by phone. RSD gave Senior Business Office Manager (BOM), Mitchell Moore permission to sign report.

As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, the facility submitted a Monthly Quality Assurance (QA) Audit that includes but is not limited to staffing, physical plant, dementia care, medication records and infection control. LPA reviewed QA and found that there were deficiencies pertaining to medications: two [2] resident rooms were not free of medications and creams/lotions were left out in resident rooms (deficiency cited, see 809D).

LPA conducted a tour of the facility that included both memory care units, the assisted living care unit and grounds. Facility appeared to be safe, sanitary and in good repair.

Facility provides monthly training to staff in order to comply with the Stipulation and Waiver, and Order and contracts with a vendor to ensure the staff training requirement is met. Per QA, check of staff training was in compliance. LPA reviewed training records of employees identified on the QA report and found documentation present, except for one employee. One employee (S1) identified as having CPR certificate present in their file actually did not have a CPR certification or training certificate present in their file. LPA contacted Director of Regulatory Compliance (DRC), person whom submitted the QA report, to ask about this discrepancy. LPA asked if there were any circumstances under which they would mark that the CPR card was present when it actually was not present, DRC answered that it must have been a mistake but will move forward with increased diligence.


Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 11/19/2024
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Continued from 809...

LPA reviewed the most recent staff schedule to verify that facility has sufficient staff for resident's needs including but not limited to residents needing two-person assists. Per conversation with Administrator, they staff two caregivers for each unit on each shift, with a rotating Med Tech that will serve as the Med Tech for both Memory Care buildings. Managers will provide additional assistance for breaks and lunches, when needed. Staffing is still an issue, but per LPA review of LIC500 and conversation with Administrator, facility has hired 8 new staff members and a new Resident Care Coordinator. New staff members are currently undergoing their training and will be added to the shift as soon as shadow training is successfully completed. Per Admin, facility is not allowing new hires to be put into the 4/2 rotation (work 4 days, then off 2 days) until they have shadowed a complete 4/2 rotation. Additionally, Admin explained that should the staff be identified not quite ready, facility will have them complete another 4/2 rotation shadowing.

Review of audit showed other minor instances of non-compliance however the instances were not significant or frequent enough to warrant a health and safety concern.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with BOM. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with BOM and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2024 06:02 PM - It Cannot Be Edited


Created By: Christi Coppo On 11/19/2024 at 04:47 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: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/27/2024
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia (2) Over-the-counter medication, nutritional supplements or vitamins... and toxic substances such as certain plants.... and disinfectants.
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Facility to conduct in-service training on proper handling and storage of items that must remain inaccessible to residents. Facility to submit training log to CCL by plan of correction due date.
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This requirement was not met by licensee as evidenced by: QA audit report indicated medications found in resident rooms and creams/lotions left out in resident rooms, which poses a 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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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