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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803751
Report Date: 06/06/2023
Date Signed: 06/06/2023 11:23:23 AM


Document Has Been Signed on 06/06/2023 11:23 AM - 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: 52DATE:
06/06/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator, Cinthya GaminoTIME COMPLETED:
11:33 AM
NARRATIVE
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Licensing Program Analyst (LPA) Bertozzi arrived unannounced to conduct a Legal Non-Compliance Case Management inspection and met with Administrator, Cinthya Gamino.

As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, the facility continues to submit monthly reports to LPA that include an LIC500 that shows staffing, resident roster that includes how many residents are two person assists, and a Monthly Quality Assurance Audit that includes but is not limited to staffing, physical plant, dementia care, medication records and infection control. Administrator also provided the most recent medication audit that was completed by a vendor.

LPA conducted a tour of the facility around 9:00am with Administrator that included both memory care units, the assisted living care unit and the grounds.

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. Administrator provided LPA with proof of training for Managers Caregivers and Medication Technicians.

LPA reviewed the most recent staff schedule to confirm that facility has sufficient staff for resident's needs including but not limited to residents needing two person assists. Per conversation with Administrator, they continue to staff two caregivers for each unit on each shift to ensure sufficient staffing. Managers and Medication Technicians provide additional assistance for breaks and lunches, if needed.

Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
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


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: 06/06/2023
NARRATIVE
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Continued from LIC809

Facility continues to submit Special Incident Reports within the regulatory time frame. Facility recently reported an elopement of a resident who resides in Memory Care. Per discussion with Administrator, they believe that the resident followed a staff or visitor out of the memory care unit. Facility followed their elopement protocol and resident was found about a block from the facility. Resident had a skin tear but facility was unsure if the resident had fallen so they were sent to the hospital. No additional injuries were noted and resident returned to the facility the same day.

Review of audits showed some minor instances of non-compliance however the instances were not significant or frequent enough to warrant a health and safety concern. Issues noted in the audit were immediately remedied by the facility.

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: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/06/2023 11:23 AM - 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: 06/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2023
Section Cited
CCR
87464(f)

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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care & supervision as defined in...Health and Safety Code section 1569.2(c). Health & Safety Code section 1569.2(c) provides: (c) "Care & supervision" means the facility assumes responsibility for, or provides or promises
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Administrator has conducted an in-service for all staff regarding elopements. Training including staff being more observant when visitors and staff leave the memory care unit to ensure that residents are not following. Deficiency is cleared.
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to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Requirement was not met as evidenced by resident eloping the facility. This is an immediate Health & Safety risk.
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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: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3