496803751-9-19-2023-21-AS-BMOS-CW8THN-20231002144502

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803751
Report Date: 09/19/2023
Date Signed: 09/19/2023 02:51:21 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
09/13/2023 and conducted by Evaluator Victoria Bertozzi

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230913130434

FACILITY NAME:	HEALDSBURG SENIOR LIVING COMMUNITY		FACILITY NUMBER:	496803751
ADMINISTRATOR:	GAMINO, CINTHYA		FACILITY TYPE:	740
ADDRESS:	725 GROVE STREET		TELEPHONE:	(707) 433-4877
CITY:	HEALDSBURG	STATE: CA	ZIP CODE:	95448
CAPACITY:	82	CENSUS: 42	DATE:	09/19/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Administrator, Cinthya Gamino		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not administer resident's medications as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Victoria Bertozzi and Helena Rummonds arrived unannounced to conduct a complaint investigation regarding the above complaint and met with Administrator, Cinthya Gamino.

Staff did not administer resident's medications as prescribed - Complaint alleges that facility gave incorrect medication and resident was sent to the Emergency Room. LPAs spoke with Administatrator who confirmed that resident, R1 was given another resident's medication in error. Following error, resident was sent to the Emergency Room but returned the same day without experiencing any adverse affects. LPAs reviewed facility incident report, chart notes and the discharge paperwrok from the hospital.
Based on interview and review of documents, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.
California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230913130434

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: 09/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/20/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical & dental care shall be developed by each facility. Plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with	1 2 3 4 5 6 7	Facility has conducted additional training to medication technicians and provided proof of inservice to LPA. Additional medication training through a vendor is planned for 9/20/2023. Deficiency is cleared.
	8 9 10 11 12 13 14	self-administered medications. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by R1 being given incorrect medication which poses an immediate health & safety risk to residents.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

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