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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803751
Report Date: 12/12/2024
Date Signed: 12/12/2024 06:54:24 PM

Document Has Been Signed on 12/12/2024 06:54 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/
DIRECTOR:		MAY,JERALYNFACILITY TYPE:
740
ADDRESS:725 GROVE STREETTELEPHONE:
(707) 433-4877
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY: 82CENSUS: 46DATE:
12/12/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:41 PM
MET WITH:Jeralyn MayTIME VISIT/
INSPECTION COMPLETED:
07:09 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Legal Non-Compliance Case Management inspection.

The following items were indicated as deficient in the most recent audit dated 12/2/24:
  • Pharmacy transaction binder not organized and/or complete in Memory Care (building not specified)
  • Resident call/signal/pager system was not operating properly in that facility having issues with resetting
  • First Aid Kits missing items
  • Medication requiring refrigeration temperature log was missing signatures
  • Narcotics being signed off and counted for each shift log was missing signatures

The following items are some of the requirements required per the current Stipulation and Waiver and Order (dated 6/30/22) in place for the facility:
  1. All staff that provide medication administration must receive one additional hour of training every month
  2. Pacifica shall perform quarterly audits of medication inventory and if errors are found, a plan of correction for each error found shall be included with the applicable audit report
  3. Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Med Tech will not be a direct care staff, but may provide support when not distributing medication.
  4. Facility call system and delayed egress shall at all times be fully functional

As pertains to item #2, LPA observed signature missing on narcotics log check for this morning 12/12/24. Staff (S2) advised LPA that she hadn't signed the log yet. The time was 12:38pm. Audit identified the same issue on 12/2/24. Plan of correction not received when audit was submitted as required by the current Stipulation and Waiver and Order in place for the facility.


Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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: 12/12/2024
NARRATIVE
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Continued form 809...

As pertains to item #3, LPA observed two [2] staff present Memory Care building 1 (MC1) but no med tech present. LPA reviewed facility staff schedule for 12/12/24 and found that S2 was scheduled to rotate between Assisted Living (AL) and MC1. LPA verified schedule is current and accurate with S2. Therefore, facility was found to be deficient in requirement required as part of the current Stipulation and Waiver and Order in place for the facility (deficiency cited, see 809D**civil penaltiy assessed**).


As pertains to item #4, LPA observed the pendant call button system to not be properly working. LPA interviewed resident in room 101 (R2). LPA pressed resident's pendant at 11:34am. Staff (S1) arrived at 11:42am to room 101 to take the resident down for lunch. LPA asked caregiver if they were here to answer the pendant call, they said no, and explained that they did not receive a page and were here to take the resident to lunch. Care giver then proceeded to wheel the resident down to the dining area. Admin was approaching down the hall as S1 was leaving. LPA advised Admin of pendant alarm not working. LPA confirmed with Admin that pendant flashed red when LPA pressed it. The pendants flash red when they are activated then turn green once reset/answered by staff. The staff are to receive a page when the pendant is pushed and the call is also logged on the pendant/call button computer. Admin and LPA went to review computer call button log and there was no call showing from room 101. Admin went to resident in dining hall and pressed resident's pendant, S1 was present as well. Once again S1 did not receive the page and the call request was not logged on the call button computer log. Issue reported in audit dated 12/2/24 was "Resident call/signal/pager system was not operating properly in that facility having issues with resetting." However, no plan of correction was submitted with audit as required by the current Stipulation and Waiver and Order in place for the facility (deficiency cited on annual inspection 809D dated 12/12/24).

One [1] staff (S6) out of three [3] staff identified in audit as having completed orientation training and CPR card on file were found to actually not be on file and not issued. LPA confirmed with Admin that S6 does not have completed orientation training and current CPR card (deficiency cited on annual inspection 809D dated 12/12/24).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Admin. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2024 06:54 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/12/2024 at 03:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
12/12/2024
Section Cited
CCR
87705(c)(4)

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87705 Care of Persons with Dementia (c) (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and heakth care needs. as identified in their current appraisal/care plan. This requirement was not met by licensee as evidenced by:
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Facility to submit to CCL facility staff schedule showing Med Tech present in each building without an any rotation between buildings as required per the current Stipulation and Waiver and Order in place for the facility. Facility to also submit LIC500 showing adequate staffing
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Based on LPA observation and interview staff schedule for 12/12/24 shows that S2 was scheduled to rotate between Assisted Living (AL) and MC1, which is a defieicncy of the requirements oulined in the current Stipulation and Waiver and Order dated 6/30/2022, which poses a potential health, safety or personal rights risk to persons in care.
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in both Memory Care buildings, in numbers at least as much as outlined in the Stipulation and Waiver and Order dated 6/30/2022 or greater, and in numbers that ensure meeting each resident’s physical, social, emotional, safety and health care needs as identified in their current appraisal/care plan and/or physician's report.**civil penaltiy assessed**

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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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