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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803751
Report Date: 02/24/2023
Date Signed: 02/24/2023 02:41:23 PM


Document Has Been Signed on 02/24/2023 02:41 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:ALVAREZ, CINTHYAFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 46DATE:
02/24/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Cinthya GaminoTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Post Licensing Inspection and met with Administrator, Cinthya Gamino . The inspection is focused the Infection Control procedures and practices of this facility but LPA made additional observations.

Upon arrival, staff checked LPA's temperature and LPA completed a questionnaire with standard Covid-19 questions. Administrator and LPA discussed the upcoming changes to Covid guidance. LPA initiated a tour of the facility which included the main Assisted Living building that contains the main kitchen and dining room and two Memory Care Units around 10:45am and observed the following: Facility was a comfortable temperature and exits were free from obstruction. LPA tested the water in a sampling of resident rooms and temperatures were within regulation. A bottle of bleach was located in a laundry room cabinet, accessible to residents in care. Additionally, the storage room that houses disinfectants was unlocked making those items accessible to residents in care. Hand sanitizer was available throughout common areas. LPA observed staff wearing masks during this visit. Commonly touched surfaces are disinfected at least once per day.

The construction area of the facility is fenced to ensure resident safety. Facility has required Complaint Posters as well as Resident Rights posters. Activity posters were observed in each unit. An area for resident and families to provide comments has been created following LPA's directive regarding having an area designated for Family and Resident Council notices but does not have space for the Family or Resident Council to post. LPA has clarified with Administrator what the requirement is so they will add an area for Council postings.

Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 02/24/2023 02:41 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having disinfectants accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2023
Plan of Correction
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 Bleach was returned to the storage room and room was locked immediately. Administrator plans to provide an in-service with housekeeping staff to ensure disinfectants are always stored inaccessible to residents in care. Deficiency cleared during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 02/24/2023
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Continued from LIC809

Fire extinguishers were last serviced April 2022. Facility has a vendor who comes in routinely to test the fire system which includes carbon monoxide detectors and the most recent service was conducted November 2022. Facility has a call bell system and each resident room and public restroom has a call bell. Memory care has functional delayed egresses.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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