Inspection Reports for
Healdsburg Senior Living

The facility failed to submit the required Proof of Corrections by the due date, resulting in a civil penalty assessment of $700 for the period from 1/24/2026 to 1/30/2026, with penalties continuing to accrue until correction.

The visit was initiated as a complaint investigation for Compliant Control Number 21-AS-202601221. The complaint was substantiated as the facility failed to provide requested resident records due to removal of data by the new management company.

The facility was found to be noncompliant with California Code of Regulations (CCR) 87506 Resident Records for failing to retain original or photographic reproductions of resident records for at least three years following termination of service. This deficiency was previously cited, resulting in a civil penalty of $250.

The complaint investigation was substantiated regarding the facility's failure to maintain safe conditions after a ceiling collapse injured a resident. The allegation that staff consumed alcohol while on shift was unsubstantiated due to lack of evidence.

The investigation substantiated that a ceiling collapsed in the Memory Care unit due to a water leak, causing injury to a resident. The facility failed to properly repair the leak, posing an immediate health and safety risk. Another complaint alleging staff alcohol consumption was unsubstantiated.

The facility failed to submit the required LIC 624 Unusual Incident/Injury Report within seven days of a serious injury occurrence, resulting in a cited deficiency for noncompliance with California Code of Regulations 87211 Reporting Requirements.

The facility was found to have two deficiencies related to residents not having an annual routine visit with a licensed medical professional. Staff files and other resident records were generally in compliance. The annual inspection was not completed and will continue at a later date.

The complaint alleged that due to lack of staff, a resident sustained a pressure injury. The allegation was substantiated based on interviews, record reviews, and observations.

The investigation substantiated the complaint that insufficient staffing prevented proper repositioning of resident R1, resulting in a stage 2 pressure wound. The facility had only one caregiver assigned to the entire Assisted Living unit during the relevant period, violating staffing requirements.

The complaint investigation was substantiated for failure to meet resident care needs due to insufficient staffing and improper assistance. The allegations of inadequate staff training and unlawful eviction were unsubstantiated due to lack of evidence.

The investigation substantiated that staff failed to meet the care needs of resident R1, including insufficient staffing and failure to provide required two-person assistance for transfers. The allegation of inadequate staff training was unsubstantiated, as caregivers had completed required training. The allegation of unlawful eviction was also unsubstantiated due to lack of evidence.

The visit followed a complaint investigation on 2025-10-23 regarding missing documentation for a former resident (R1).

The facility was found not to have maintained original or photographic reproductions of a former resident's records as required by California Code of Regulations 87506. The management company had removed data from facility computers, and requested documentation was not provided on site.

The facility was found to have insufficient staffing in Memory Care Units and Assisted Living, with repeated deficiencies leading to a civil penalty. Additionally, the construction area was unsecured, posing trip hazards and exposure to toxins, resulting in another citation.

The complaint investigation was substantiated for inadequate staffing but unsubstantiated for telephone service availability. The facility was cited for repeated deficiencies and assessed a $1000 civil penalty.

The allegation of inadequate staffing was substantiated due to insufficient direct care staff in Memory Care building 2 and Assisted Living, including failure to meet two-person assist requirements and manage aggressive resident behaviors. The allegation regarding telephone service availability was unsubstantiated as no evidence of telephone outage was found.

The facility was found to have inadequate staffing in Memory Care 2 and Assisted Living units, and a staff member failed to complete required medication administration training for May and June 2025. Medications for four residents were properly stored and documented.

The complaint alleged inadequate staffing to meet resident needs, specifically that only one direct care provider was scheduled per shift despite some residents requiring two-person assist. The allegation was substantiated based on staff schedule review and resident care needs.

The investigation substantiated the complaint, finding that staffing in Memory Care units 1 and 2 was insufficient to meet the needs of residents requiring two-person assist. Staff lunch breaks were not staggered, resulting in only one direct care staff present during lunch periods, which is out of compliance with the facility's Stipulation and Order.

This inspection was complaint-related, triggered by a Legal Non-Compliance Case Management visit. Deficiency related to staffing in Memory Care was cited under Complaint #21-AS-20250501120816.

The facility was found deficient in medication management, dementia care, dining services, and staffing requirements per stipulation and waiver orders. Several deficiencies related to discontinued medications, lack of monthly activity calendars, unsafe storage of items, and inadequate food handling were cited. Minor non-compliance instances were noted but not significant enough to pose health and safety concerns.

Complaint findings substantiated related to staff training deficiencies; seven of seven staff lacked required annual training hours.

The facility failed to correct multiple deficiencies related to food safety, staff training, and CPR/first aid certification. Deficiencies from prior annual and complaint inspections were re-cited due to lack of submitted or accepted plans of correction. The facility submitted a Quality Assurance audit indicating some compliance but clarification on training documentation is needed.

The inspection found multiple deficiencies including incomplete pharmacy transaction binder, malfunctioning resident call/signal/pager system, missing items in first aid kits, missing signatures on medication refrigeration and narcotics logs, staffing issues with Med Tech rotation between units, and incomplete staff orientation and CPR training documentation. Civil penalties were assessed for staffing deficiencies.

The inspection identified multiple deficiencies including issues with food storage and labeling, malfunctioning pendant call button system, missing medication log entries, and incomplete staff CPR and training records.

The facility was found to have deficiencies related to medications being left in resident rooms, which poses a health and safety risk. Staff training records were generally compliant except for one employee lacking CPR certification documentation. Staffing remains an issue but improvements are underway with new hires and training. The facility appeared safe, sanitary, and in good repair overall.

The facility failed to meet the plan of correction requirements for the pendant call button system, with 26 calls answered in more than 15 minutes between 10/30/24 and 11/3/24, including one over an hour. The facility has since completed repairs, provided additional staff training, and disciplined employees with slow response times.

The complaint investigation was substantiated. Allegations included inadequate training of housekeeping staff performing caregiving duties, insufficient staffing leading to unmet resident needs and personal rights violations, and delayed or absent responses to resident call pendant alerts. The facility failed to meet regulatory requirements, posing potential health, safety, and personal rights risks to residents.

The investigation substantiated multiple allegations including inadequate training of housekeeping staff performing caregiving duties, insufficient staffing in Memory Care building #1 leading to unmet resident care needs, and delayed or absent responses to resident pendant call button alerts. These deficiencies pose potential health, safety, and personal rights risks to residents.

The complaint alleged that staff did not administer resident's medications as prescribed. The allegation was substantiated based on interviews and document reviews.

The investigation substantiated that a resident was given another resident's medication in error, resulting in the resident being sent to the Emergency Room but returning the same day without adverse effects. The facility failed to comply with regulations requiring assistance with self-administered medications.

The facility continues to submit required reports and provide staff training as mandated. A recent resident elopement was reported and managed according to protocol. Minor non-compliance issues were noted but were not significant or frequent enough to pose health and safety concerns and were promptly corrected.

The visit was complaint-related, following a self-reported incident of a resident missing medication. The deficiency was substantiated and corrective action was taken.

The facility failed to ensure timely receipt of a resident's medication due to an error in communication with the pharmacy and staff oversight. The Medication Technician was re-trained to prevent recurrence.

The facility was generally compliant with infection control and safety standards, but disinfectants were found accessible to residents, posing a safety risk. The deficiency was corrected during the inspection. Fire safety systems and call bell systems were verified as functional.