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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803751
Report Date: 07/24/2025
Date Signed: 07/24/2025 03:28:45 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
06/25/2025 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20250625095039
FACILITY NAME:HEALDSBURG SENIOR LIVING COMMUNITYFACILITY NUMBER:
496803751
ADMINISTRATOR:RODRIGUEZ, BRANDEEFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 39DATE:
07/24/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Brandee Rodriguez, Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Inadequate Staffing

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegation and met with facility Administrator Brandee Rodriguez.

Complaint alleges the 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 in Memory Care Building 2 and Assisted Living, but the care needs of residents require at least two (2) staff be present, as some residents require a two (2) person assist and some resident’s behaviors require at least two (2) staff members, as one (1) staff member is needed solely for the purpose of redirecting the residents with disruptive and or aggressive behaviors.

Continued on 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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 4
Control Number 21-AS-20250625095039
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: 07/24/2025
NARRATIVE
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...Continued from 9099

The 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. In addition, page five (5) line items 5-7 state that a census of each unit and any two (2) person assist be identified.

During the investigation, LPA reviewed staff schedules from 6/18/2025 through 7/2/2025 for Memory Care building 1 (MC1), Memory Care building 2 (MC2) and the Assisted Living building (AL). LPA observed that there was only one (1) Caregiver scheduled for MC2 and AL per shift during this time frame. LPA further observed that on the two (2) person assist census dated 6/13/2025, MC2 residents R2 and R3 were listed as needing a two (2) person assist; however, on the two (2) person assist census dated twelve (12) days later on 6/25/2025 the same two (2) residents were not listed as requiring a two (2) person assist. During records review, LPA observed that there was no change in conditions for these two residents. Additionally, resident R4, who lives in assisted living was listed as requiring a two person assist.

During interviews conducted with staff, both S1 and S2 stated that MC2 Resident R1 displays aggressive and disruptive behaviors that require a staff member to address and or redirect resident. During this time, a second (2nd) staff member is required to monitor the other residents. During charting note review, LPA observed fourteen (14) instances of aggressive behavior from R1 towards staff and other residents between the dates of 6/4/2025 to 7/1/2025.

Based on LPA record review and interviews, 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. The facility was cited for the same deficiency on10/16/2024, 11/19/2024 and 5/6/2025. As this repeat deficiency occurred within one (1) year of the previous citations, a Civil Penalty of $1000.00 will be assessed.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20250625095039
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: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2025
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. This requirement was not met by licensee as evidenced by
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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 7/25/2025. Facility to submit to CCL updated LIC500 with staff schedules showing adequate staffing by no later than 8/15/2025.
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Based on record review and interviews the licensee did not comply with the section cited above in that staffing in MC2 & AL is not sufficient per resident care needs including but not limited to 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: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
06/25/2025 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20250625095039

FACILITY NAME:HEALDSBURG SENIOR LIVING COMMUNITYFACILITY NUMBER:
496803751
ADMINISTRATOR:RODRIGUEZ, BRANDEEFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 39DATE:
07/24/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Brandee Rodriguez, Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility and/or Staff did not ensure telephone service was available to residents in care
INVESTIGATION FINDINGS:
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Complaint alleges the facility did not ensure that telephone service was available to residents in care.

During the investigation LPA interviewed staff and reviewed records.

Staff members S1, S2 and S3 stated that they were unaware of any telephone outage in Memory Care building 1 (MC1), Memory Care building 2 (MC2) and the Assisted Living building (AL). Record review did not indicate that there was any telephone outage.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4