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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 06:06:00 PM

Document Has Been Signed on 11/19/2024 06:06 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:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:05 PM
MET WITH:Business Office Manager, MItchell MooreTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management to follow up on Incident report submitted 10/23/24 and to conduct a plan of correction visit. LPA 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.

LPA reviewed Incident report submitted for resident R1. On 11/7/24 facility reported that R1 fell. R1 was observed on the ground on the backyard patio. Resident was outside sitting with all the other residents in Memory Care #2. Staff suddenly heard a chair hit the floor. A fellow resident stated to staff that she was trying to get up from her chair. R1 was on the floor with their head against the wall, resulting in a wound on the back of their head. Per LPA conversation with Admin, resident stood up and tried to support their weight on the arm of the chair and fell. Staff were present but just could not reach resident fast enough to break their fall. Fall was not a result of lack of staff supervision. R1 placed on 72 hour alert charting and increased monitoring. No deficiency cited.

LPA also present at facility to conduct a plan of correction visit. On 10/16/24 citation was issued for deficiency of Health and Safety Code 1569.269(a)(6). The plan of correction required facility to ensure that pendant call button system was in good repair and operational and for staff to be present in sufficient numbers to answer calls in a timely manner, when residents are in need of assistance. Facility was to submit three week pendant call button system log to CCL showing all calls answered within a timely manner by plan of correction due date. Admin agreed that within 15 minutes can be defined as within a timely manner. The plan of correction was due 11/14/24 as an extension was granted by LPA. On 11/13/24 Admin submitted pendant call log. Per LPA review of pendant call log, between 10/30/24 and 11/3/24, pendant response times were greater than 15 minutes a total of 26 times, with the longest being over 1 hour (deficiency cited, see 809D and civil penalty assessed).

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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Document Has Been Signed on 11/19/2024 06:06 PM - It Cannot Be Edited


Created By: Christi Coppo On 11/19/2024 at 05:21 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
12/03/2024
Section Cited
HSC
1569.269(a)(6)

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ยง1569.269 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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Facility to submit training logs and termination paperwork for employees that were identified by Admin to have struggled with resetting the pagers or did not repsonse to pendant calls within 15 minutes. Logs and paperwork to be submitted to CCL by plan of correction due date.
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This requirement was not met by licensee as evidenced by: failure to fulfill deficieny plan of correction issued on 10/16/24 for pendant call button system showing all calls answered with 15 minutes, 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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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
NARRATIVE
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continued from 809...

Per Admin, the repairs on the pendant call button system have been completed and issues appear to have been resolved. Per Admin, facility has addressed the response times longer than 15 minutes by completing additional training with those staff that struggled with resetting the pagers. Per Admin, facility had several employees on the PM and NOC shift that were not responding to the pendant calls in a timely fashion; these employees have been disciplined, and will be terminated if they continue with slow response time.

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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