Healdsburg Senior Living Community

Allegation investigated: Due to lack of staff resident sustained a pressure injury

At approximately 8:50 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegations and met with facility back up Administrator Shauna Burton. During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges that due to lack of staff resident sustained a pressure injury. The facility has five (5) levels of care for Assisted Living with level one (1) being the least amount of care and level five (5) being the highest level of care. The facility conducted Resident Assessments of resident R1 on 12/1/2024 and on 5/14/2025. Both assessments of R1 stated that R1 requires level five (5) care. Continued on 9099-C... Substantiatedthe state’s words, verbatim · CDSS document, Nov 18, 2025 · control 21-AS-20250808144348

Allegation investigated: Facility staff did not follow residents care plan Facility staff did not meet residents care needs

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegations and met with facility Administrator Brandee Rodriguez. During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges staff did not follow the resident’s care plan and that the staff did not meet the resident’s care needs. The facility has five (5) levels of care for Assisted Living with level one (1) being the least amount of care and level five (5) being the highest level of care. The facility conducted Resident Assessments of resident R1 on 12/1/2024 and on 5/14/2025. Both assessments of R1 stated that R1 requires level five (5) care. The Needs and Services Plans (NSP), reflective of the previously noted assessments, states that R1 requires “Total Assist” for Bathing, Grooming, Dressing and Ambulation. Continued on 9099-C... Substantiatedthe state’s words, verbatim · CDSS document, Oct 30, 2025 · control 21-AS-20250808144348

Allegation investigated: Inadequate Staffing

Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegation and met with facility Administrator Brandee Rodriguez. Complaint alleges the facility does not have adequate staffing to meet the needs of residents in care. Complainant states that only one direct care provider is scheduled per shift in Memory Care Building 2 and Assisted Living, but the care needs of residents require at least two (2) staff be present, as some residents require a two (2) person assist and some resident’s behaviors require at least two (2) staff members, as one (1) staff member is needed solely for the purpose of redirecting the residents with disruptive and or aggressive behaviors. Continued on 9099-C... Substantiatedthe state’s words, verbatim · CDSS document, Jul 24, 2025 · control 21-AS-20250625095039

Allegation investigated: Licensee does not ensure sufficient staffing is provided resulting in a lack of supervision for residents in care

Licensing Program Analyst (LPA) Robert Frank and arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegation and met with facility Administrator Brandee Rodriguez. Complaint alleges the facility does not have adequate staffing to meet the needs of residents in care. Complainant states that only one direct care provider is scheduled per shift in Memory Care Building 2 and Assisted Living, but the care needs of residents require at least two (2) staff be present, as some residents require a two (2) person assist and some resident’s behaviors require at least two (2) staff members, as one (1) staff member is needed solely for the purpose of redirecting the residents with disruptive and or aggressive behaviors. The same allegation of Inadequate Staffing was filed with Community Care Licensing on 6/25/2025. This same allegation on complaint control #21-AS-20250625095039 was found to be substantiated and a citation was issued. As such, this cthe state’s words, verbatim · CDSS document, Jul 24, 2025 · control 21-AS-20250714081523

Allegation investigated: Facility does not have adequate staffing to meet the needs of residents in care.

Licensing Program Analysts (LPAs) Robert Frank and Christi Coppo arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegation and met with facility Administrator Brandee Rodriguez. Complaint alleges facility does not have adequate staffing to meet the needs of residents in care. Complainant states that only one direct care provider is scheduled per shift, but the care needs of residents require at least two staff be present, as some residents require a two-person assist. During investigation, LPAs reviewed staff schedule for 5/6/25. LPAs observed that staffing for Memory Care buildings 1 and 2 (MC1)(MC2) is such that there are two caregivers scheduled with one Med Tech present. Review of schedule indicates that lunches are not scheduled such that they are staggered to ensure each Memory Care unit has two staff present at all times. Continued on 9099-C Substantiatedthe state’s words, verbatim · CDSS document, May 6, 2025 · control 21-AS-20250501120816

Allegation investigated: Licensee does not provide adequate or proper training Licensee does not ensure adequate staffing Personal Rights Residents needs are not being met

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with Jeralyn May, Administrator. Complaint alleges licensee does not provide adequate or proper training. Complainant states housekeeping personnel are doing caregiving duties without training. During investigation, seven [7] out of seven [7] staff interviewed state that housekeeping personnel are performing caregiving duties. On 7/12/2024, LPA observed staff identified as housekeeping to be working and providing care to residents in Memory Care building #1 (MC1). During investigation, LPA reviewed training records for seven [7] staff. Seven [7] out of seven [7] staff did not have current training or did not have the required amount of current training hours completed. Based on LPA’s observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regthe state’s words, verbatim · CDSS document, Oct 16, 2024 · control 21-AS-20240709101931

Allegation investigated: Staff did not administer resident's medications as prescribed

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 givthe state’s words, verbatim · CDSS document, Sep 19, 2023 · control 21-AS-20230913130434