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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803751
Report Date: 01/29/2025
Date Signed: 01/29/2025 04:31:40 PM

Document Has Been Signed on 01/29/2025 04:31 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:
01/29/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Jeralyn May, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:46 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Plan of Correction POC visit to clear citations issued to Healdsburg Senior Living on 10/16/24 and 12/12/24.

The following citations were outstanding:

CCR 87555(b)(8) - issued 12/12/24

CCR 87555(b)(23) - issued 12/12/24

HSC 1569.625(b)(2) - issued 10/16/24

HSC 1569.625(b)(1) - issued 12/12/24

HSC 1569.618(c)(3) - issued 12/12/24

On 12/12/24 LPA conducted the Annual inspection. The following citation was issued for deficiency of CCR 87555(b): Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed box of lettuce and lettuce actively being used to prepare salads to have black wilted leaf tips and/or stalks. Some the leaf tips were both black and had a white fuzzy substance present, which poses a potential health, safety or personal rights risk to persons in care. The following plan of correction was agreed upon with Admin: Facility to submit LIC9098 self-certification of proper food service training completed by all food service personnel by plan of correction due date of 1/2/25. As of today, CCL has not received plan of correction. Today, LPA and Admin toured the kitchen and found a watermelon to have a black fuzzy substance with white fuzzy substance also present. Deficiency is being re-cited today, see 809D.

Continued on 809C...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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: 01/29/2025
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Continued from 809...

On 12/12/24 LPA conducted the Annual inspection. The following citation was issued for deficiency of CCR 87555(b)(23): Based on LPA observation, the licensee did not comply with the section cited above in that Some food items observed were not covered or not labeled with date of opening: chocolate mousse, cakes, and dishes of fruit, gallon of milk and white food item that looked like mashed potatoes or riced cauliflower, which poses a potential health, safety or personal rights risk to persons in care. The following plan of correction was agreed upon with Admin: Facility to submit LIC9098 self-certification of proper food service training completed by all food service personnel by plan of correction due date of 1/2/25. As of today, CCL has not received plan of correction. Today, LPA and Admin toured the kitchen and observed the following food items not covered or not labeled with date: cart with cakes, bowls of a bread-like food item, and slices of pie. Deficiency is being re-cited today, see 809D.

On 10/16/24 LPA delivered to the facility substantiated complaint findings in relation to staff training. The following citation was issued for deficiency of Health and Safety Code (HSC) 1569.625(b)(2): Based on LPA record review, the licensee did not comply with the section cited above in that seven out of seven staff files reviewed, staff did not have the required hours of annual training completed, which poses a potential health, safety or personal rights risk to persons in care. The following plan of correction was agreed upon with Admin: Facility to ensure all staff are current in their annual training. Facility to submit to CCL current annual training records for all care staff and Medication Technicians showing current training completed by plan of correction due date of 11/6/24. As of today, CCL has not received plan of correction. On 10/31/24 LPA received plan from Admin to complete training sometime in December. LPA advised Admin that plan is accepted but deficiency remains outstanding until plan of correction is fulfilled. As of today, CCL has not received the plan of correction. Deficiency is being re-cited today, see 809D.

On 12/12/24 LPA conducted the Annual inspection. The following citation was issued for deficiency of HSC1569.625(b)(1): Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S4 and S6 do not have complete required training on file, which poses/posed a potential health, safety or personal rights risk to persons in care. The following plan of

Continued on 809C(2)...

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

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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Page: 2 of 9
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: 01/29/2025
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correction was agreed upon with Admin: Facility to submit proof of completed required orientation training for S4 and S6 by plan of correction due date. On 1/7/25 LPA received from Business Operations Manager (BOM) some items that did not fulfill the plan of correction. LPA responded: for the training, for S6 I do not see anything that is current, I need the current completed training as outlined in the regulation. I did the annual on 12/12/24. So, anything after 12/12/23 counts as “current.” For S5, I see a whole bunch of tests and another more detailed Pacifica-specific training log. I need the trainings completed that satisfy the regulation. As of today, CCL has not received plan of correction. Deficiency is being re-cited today, see 809D.

LPA discussed with Admin, per the Stipulation and Waiver; and Order page three [3], line items 25-27 and page four [4], line items 1-11, facility shall retain a vendor to provide a minimum of four [4] hours of training monthly to all direct care staff and managers. The training topics shall include the following: job duty expectations, falls/fall response, incontinence care, basic services, prohibited health conditions, personal rights of residents. Reporting requirements, observation of changes in client conditions, requirements for updated medical and functional assessments, dementia related behaviors, maintaining required records for staff and residents, COVID screening processes, and infection control/general sanitation. Further, all staff who provide medication administration must receive one hour of additional training every month. Medication training shall be provided by a Registered Nurse licensed in the State of California.

On 12/12/24 LPA conducted the Annual inspection. The following citation was issued for deficiency of HSC 1569.618(c)(3): Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S3, S4, S5 and S6 did not have current 1st Aid/CPR on file, which poses a potential health, safety or personal rights risk to persons in care. The following plan of correction was agreed upon with Admin: Facility to submit picture of current CPR cards for S3, S4, S5 and S6 by plan of correction due date. On 1/2/25 LPA received proof of CPR for S5 and S6, but not S3 and S4. As of today, CCL has not received plan of correction for S3, and S4. Deficiency is being re-cited today, see 809D.

Continued on 809C(3)...

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

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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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: 01/29/2025
NARRATIVE
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The following deficiencies are being re-cited today for failure to correct:

HSC 1569.625(b)(2)

HSC 1569.625(b)(1)

HSC 1569.618(c)(3)

CCR 87555(b)(8)

CCR 87555(b)(23)

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 Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

LPA reviewed in detail the Stipulation and Waiver; and Order dated July 18, 2022 with Administrator Jeralyn May. In 2024, LPA only received three [3] LIC 500s: dated 9/11/24, 11/6/24 and one 1/2/25. However, 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. LPA and Admin discussed the language of the Stipulation and Waiver pages two [2] through six [6] that addresses the need for continuity of compliance. LPA gave Admin a hard copy of Stipulation.

As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, page three [3] line items 17-24, on 1/6/25 the facility submitted a Monthly Quality Assurance (QA) Audit too CCL. The QA includes




Continued on 809C(4)
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
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: 01/29/2025
NARRATIVE
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Continued from 809C(3)

but is not limited to staffing, dining, physical plant, resident rooms, infection control, medication room/cart, and dementia care. LPA reviewed QA and found the following items were indicated as deficient in the most recent audit dated 1/6/25:
· Flooring tiles in 300 wing of facility being repaired
· Current month’s activity calendar for Memory Care is not up, showing previous month’s calendar

Facility provides monthly training to staff in order to comply with the Stipulation and Waiver; and Order and contracts with a vendor to provide the staff training required per the Stipulation and Waiver; and Order. Per QA, facility’s check of staff training was in compliance. LPA reviewed training records, fingerprint clearance, and 1st Aid/CPR of employees identified on the QA report and found documentation to be present. However, training documentation procedure and requirement as outlined in the Stipulation and Waiver; and Order are requires clarification. Admin will attend meeting for clarification at Regional Office in Santa Rosa at a date to be determined.



LPA discussed with Admin staffing section of submitted QA. Comments indicate one of the selected staff (S7) is a caregiver and has 1st Aid present only, CPR not required. LPA discussed with Admin the specifications per the QA says: verify First Aid and CPR card is on file and current. LPA discussed with Admin, only one person on duty is required to have CPR.

Additionally, LPA met with licensee's auditor (A1) to discuss findings on most recent audit dated 1/6/25. LPA advised that staff (S7) was reported as having 1st Aid training but not required to have CPR. LPA showed A1 the certificate present in S7's file showing they actually do have both 1st Aid and CPR. A1 responded that the certificate is not proof of either First Aid or CPR, only that they completed an online course. LPA then advised if that is correct, and the certificate present actually is not proof, then there is still an inaccuracy. LPA received clarification from Licensing Program Manager (LPM) that certificate is proof of completed 1st Aid. LPA discussed with A1 and Regional Director of Operations (RDO) the regulation requiring that all staff must

Continued on 809C(5)
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 01/29/2025 04:31 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/29/2025 at 01:22 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2025
Section Cited
CCR
87555(b)(8)

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(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
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Facility to submit LIC9098 self-certification of proper food service training completed by all food service personnel by plan of correction due date.
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This requirement is not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPA and Admin toured the kitchen and observed the following food items not covered or not labeled with date: cart with cakes, bowls of a bread-like food item, and slices of pie, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
01/30/2025
Section Cited
CCR87555(b)(23)

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(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.
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Facility to submit LIC9098 self-certification of proper food service training completed by all food service personnel by plan of correction due date.
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This requirement is not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that the following food items were not covered and/or not labeled with date: cart with cakes, bowls of a bread-like food item, and slices of pie, 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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


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Document Has Been Signed on 01/29/2025 04:31 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/29/2025 at 01:53 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2025
Section Cited
HSC
1569.618(c)(3)

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(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty...
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Facility to submit plan to submit picture of current CPR cards for S3 and S4 by plan of correction due date. Picture of current 1st Aid/CPR cards for S3 and S4 no later than 2/12/25.
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This requirement is not met as evidenced by: Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S3 ands S4 did not have current CPR on file, which poses an immedisate health, safety or personal rights risk to persons in care.
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Type A
01/30/2025
Section Cited
HSC1569.625(b)(1)

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(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.
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Facility to submit LIC9098 self-certifying that Admin will attend the Regional Office Meeting to obtain clarification of training required. Once clarification is obtained facility to submit proof of training for S4 and S6 within 3 weeks from the date of the meeting.
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This requirement is not met as evidenced by: Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S4 and S6 do not have complete required training on file, 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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2025 04:31 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/29/2025 at 01:57 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2025
Section Cited
HSC
1569.625(b)(2)

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§1569.625 Staff training... (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...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
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Facility to submit LIC9098 self-certifying that Admin will attend the Regional Office Meeting to obtain clarification of training required. Once clarification is obtained facility to submit proof of training for all direct care staff and Med Techs within 3 weeks from the date of the meeting.
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seven out of seven staff files reviewed, staff did not have the required hours of annual training completed, 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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
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: 01/29/2025
NARRATIVE
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Continued from 809C(4)

have 1st Aid training, but that only one person on duty is required to have CPR. RDO advised that they ensure all Med Techs have CPR. LPA clarified with A1 and RDO that the staff identified on the QA should have both 1st Aid and CPR as that is what is specified on the QA form. So, A1 should be selecting staff that are required to have it as part of their audit. Therefore, all staff identified on the QA for item #3 under section of Staffing should have both First Aid and CPR.

LPA discussed with Admin that on 12/12/24, LPA conducted a Legal Non-Compliance Case Management inspection per the Stipulation and Waiver; and Order dated July 18, 2022. Staff (S6) identified in the audit as having completed training was found not to have completed training on file in the required number of hours.

LPA discussed with Admin that on 11/16/24 LPA conducted a Legal Non-Compliance Case Management inspection per the Stipulation and Waiver; and Order dated July 18, 2022. LPA reviewed training records of employees identified on the QA report as having training completed 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 conducted a tour of the facility that included memory care unit 1, the assisted living care unit and facility grounds. Facility appeared to be safe, sanitary, and in good repair.

There is an appeal pertaining to citation issued 12/12/24 for deficiency of regulation 87705(c)(4) submitted by the facility to CCL currently pending.

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

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

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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