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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803751
Report Date: 11/28/2023
Date Signed: 11/28/2023 03:49:35 PM


Document Has Been Signed on 11/28/2023 03:49 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:GAMINO, CINTHYAFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:82CENSUS: 53DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator, Cinthya GaminoTIME COMPLETED:
04:00 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Cinthya Gamino.

LPA initiated a tour of the facility around 9:50am which included the main Assisted Living building that contains the main kitchen, dining room as well as two separate buildings that contain Memory Care Units 1 and 2 and observed the following: Facility buildings were a comfortable temperature and exits were free from obstruction. LPA went into a sample of resident apartments and found them to be furnished per regulation. Water temperature in apartments tested measured at 89, 111, 115 and 119 degrees F which are not all within the range of 105 to 120 degrees F allowed per regulation. Cleaning supplies and other toxins are locked in various storage rooms and housekeeping carts to ensure resident safety. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications are centrally stored and locked in Medication Rooms and Medication Carts in Assisted Living and both Memory Care Units. Facility has required posters in main areas of the facility.

Fire extinguishers were last serviced April 2023. 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 2023. Facility has a call bell system and each resident room and public restroom has a call bell. Memory care has functional delayed egresses.

Six staff files and seven resident files were reviewed. Staff have required First Aid and CPR certificates. Training Records for staff and Medication Records for residents were reviewed. Administrator Certificate for Administrator, Cinthya Gamino, 6062514740, expires 3/3/2024. .

Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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: 11/28/2023
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Continued from LIC809

Construction areas at the facility have been made inaccessible to ensure resident safety. A building that is under construction in the back of the facility has a fence around it and the former skilled nursing area of the facility that is being remodeled has locking doors to restrict access.

Administrator to submit updates of the following documents by 12/28/2023:
LIC 308 Designation of Facility Responsibility (if applicable)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (review and update if changes)
Infection Control Plan (if changes)
Liability Insurance

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
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