Healdsburg Senior Living

The California Department of Social Services Community Care Licensing Division received a complaint on Dec. 18, 2020 regarding Healdsburg Senior Living, alleging that the facility has insufficient staffing and staff training, and isn’t meeting its residents’ needs.

The complaint is one of many that the facility has received over the years.

Separately, a Jan. 7 community care licensing facility evaluation report found that the former interim administrator did not meet the required administrator duties of developing an administrator plan and procedure to ensure clear definition of lines of responsibility, workloads and adequate supervision and that the facility failed to ensure the health and safety of clients in care by not having the proper protocols in place.

The new findings echo recent complaints and accounts from people whose parents live at the facility.

The Tribune reached out to the interim director/administrator several times via email regarding interview questions and a request for comment, which was sent via email following a phone call with them, in an effort to get their side of the story.

Additional attempts to reach out to the interim director's superior and the new director/administrator were also unsuccessful.

In total, The Tribune reached out to facility administration nine times in an effort to receive their comments on the complaints and allegations and did not receive a response.

Family Fears

Shannon Barton-Wren, whose 95-year-old mother is a resident at the facility, also recently submitted a similar complaint and said she believes her mother’s needs aren’t being adequately met and that there’s insufficient staffing and staff oversight.

The Tribune wasn’t able to confirm whether or not the Dec. 18 complaint was Wren’s complaint, since much of the information often contained in complaints is considered confidential, according to Scott Murray, a spokesperson for the California Department of Social Services.

Two months ago, Barton-Wren had written a glowing review of the Healdsburg Senior Living facility but soon after that she noticed things started to go downhill.

“At that time things weren’t too bad. When my mother entered this place, I think three years ago, it was a family-run business and all of the management were very caring and hardworking people who did more than their job descriptions to take care of everybody. It has since then been bought by a large corporation called Pacifica Senior Living,” Barton-Wren said.

Barton-Wren said she now has concerns regarding adequate staffing and whether or not all of her mother’s needs are adequately being met.

Specifically, her concern of inadequate staffing stems from the fact that at the time there wasn’t a permanent administrator of the facility who is present on a permanent, long-term basis.

At the time, the facility was being headed by an interim director/administrator, Amanda North, who allegedly had to travel back and forth to the facility.

A permanent executive director took North’s place and started in mid-January.

“There is no deputy or assistant, so the facility was without management during her absence. Five people were ambulanced to the hospital during that time, two with serious falls that may have been preventable with sufficient and adequately trained staff,” Barton-Wren alleged in an interview before the new executive director started.

Barton-Wren is also worried that her mother’s needs, which include dressing and grooming aid, aren’t sufficiently being met.

“I was allowed to go to my mother’s apartment to check and it was dirty, there were soiled Depends in the bin in the bathroom,” she said.

She said she had asked the facility how to get into contact with the person responsible for housekeeping, but was not able to get in contact with housekeeping.

“There are so many things not being attended to. During FaceTime calls I’ve seen my mother wearing the same clothes three days in a row. She needs help dressing so I have to assume she slept in them … I’m worried about the safety of my mother as well as all the other vulnerable residents,” Barton-Wren said.

Barton-Wren said she’s not the only one concerned about the general staffing, oversight and quality of care.

“I know for a fact there are several families that are as concerned as I am. There are a lot of people who are concerned,” she said.

Janice Opferman, whose father is a resident at the facility, is concerned with the quality of care and communication between staff and families of residents.

“I’ve been concerned about the care there for a while now,” she said, adding that she was upset with the fact that allegedly no one at the facility notified her that there was COVID-19 in the same building where her father lives.

“I didn’t know that there was COVID in the building, no one notified me that there was COVID, I found out by accident on Dec. 17 when I dropped off some regular medication for my dad and saw the PPE and I said, ‘What’s going on?’ to the care worker at the door and she said we have COVID.”

Opferman called the reception desk and asked if her father could be tested the following day. His test came back negative and he was retested shortly after.

“I did not hear about Monday’s test and then on Christmas Eve I called to talk to my dad and they said, ‘By the way, your dad’s test came back positive,’ and I thought why hadn’t they gotten a hold of me sooner? I could have contacted his doctor and maybe have done something,” Opferman said.

She said they claimed they sent her and her daughter an email on Dec. 11 regarding COVID-19 and the related tests but she says neither her nor her daughter received it.

By Sunday her dad had a 101 fever and she asked the facility to take him to the hospital.

“He was taken to the hospital … and I called over there a couple of hours later and they said he’s been sent back to the care home. They said he didn’t have a fever when he left here,” Opferman said.

They gave him some fluids and antibiotics and Opferman said the next day he was in pain and was sent back to the hospital and ended up not eating on his own.

He was eventually transferred back to the facility. Opferman said she desperately didn’t want him to go back there due to the concerns with care and staffing.

“The next morning the hospice nurse called me and said he had two falls. I was so upset. Hospice sent people in there every day because they said the conditions were deplorable and very short of staff … and said that my concerns were valid,” Opferman said.

When asked if the facility administration had done anything to address her concerns Opferman said, “Not as far as I’m concerned.”

When asked what the basis of a complaint would be if she were to complain she said, “That they didn’t have enough staffing, that there’s been no management whatsoever and I did put in a complaint with Victoria Willis of licensing … She said there are a lot of complaints and that they (the licensing division of the California Department of Social Services) are working on it and that there’s an active investigation ongoing.”

Formal evaluations

On Dec. 31, the community care licensing division of the California Department of Social Services made an unannounced evaluation visit to the facility to address several areas of concern, COVID-19 protocols including infection control and personal protective equipment (PPE), adequate staffing and general oversight.

During the visit, Licensing Program Analyst Victoria Willis, Licensing Program Manager Bethany Moellers and Assistant Program Administrator Pam Gill met with then-Acting Administrator North and representatives from Pacifica Senior Living, Marlene Nelson and Jackie Bobbitt via teleconference to conduct an informal conference to discuss the concerns.

Following their discussion licensing requested the following documents to be submitted, a LIC500 personnel report, proof of training for donning and doffing of PPE and infection control and an updated mitigation plan to include disinfecting of the facility.

North and Bobbitt did not reply to several requests for comments regarding the facility concerns and the unannounced visit.

On Jan. 7, community care licensing conducted a non-compliance conference with North; Resident Care Coordinator Trulynia Coiner; Pacifica Senior Living representatives Carl Knepler; Frank Perez; Jackie Bobbitt; and Marlene Nelson, director of quality assurance and risk management.

The reason for the teleconference was to discuss areas of concern with the administration, facility and with COVID-19.

According to the facility evaluation that was conducted as part of the non-compliance conference, several community care licensing requirements were not met.

Based on records, reviews, observations and interviews, it was determined that the administrator at the time did not meet their required duties of developing an administrative plan and procedure to ensure clear definition of lines of responsibility, equitable workloads and adequate supervision.

Additionally, the facility, “Failed to satisfactory follow guidelines that the department recommended signage of COVID-19 after receiving 1st (+) staff which poses an immediate health and safety risk to residents in care,” according to the report.

The facility also did not meet the requirement of conduct that is “inimical to health, morals, welfare or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home. This requirement has not been met based on records review, observation and (the) facility failed to ensure implementation of a mitigation plan, staffing plan, cleaning schedule to mitigate the spread of COVID-19.”

It was also found that the requirement to have safe, healthful and comfortable accommodations and to provide care, supervision and services that meet the needs and are delivered by staff that are sufficient in numbers, qualifications and competency were also not met.

Thus it was found, based on interviews, records and observations by community care licensing, that the facility failed to ensure the health and safety of the clients in their care by not having proper protocols in place.

All of these instances are Type A deficiencies — deficiencies that have immediate impacts to health and safety.

“Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties,” the evaluation report states.

The Tribune reached out to the facility administrator several times in an attempt to get their thoughts on the matter but never heard back.

History of complaints

The facility — under the licensing of Avalon Healthcare Management LLC —  has undergone 13 investigations into complaints received over the last five years. There have been a total of 16 complaint-related visits by the community care licensing division.

Nine complaint investigations have been completed so far. Five complaint allegations have been substantiated, two were found inconclusive, six were unfounded and 16 were unsubstantiated.

Over the same time period, the facility has received five Type A citations, which denote immediate health, safety or personal rights impact. It has received 16 Type B citations, which denote potential health, safety or personal rights impacts.

“Type A citations pose an immediate threat to residents in care and must be corrected within 24 hours,” Murray said.

The most recent investigation was into a complaint received on March 2, 2020 alleging that the facility failed to seek timely medical attention for a resident and failed to notify an authorized representative of an incident regarding a resident.

The two allegations were substantiated following a lengthy investigation.

During the investigation the licensing department conducted interviews with staff, medical professionals and other involved parties, and reviewed documents and observations.

“Based on multiple interviews and a review of various documents the department learned that Resident R1 had an unwitnessed fall on Feb. 24, 2020, however, R1 was not sent to the hospital until Feb. 27, at which time was diagnosed with a hip injury. According to interviews, staff noted at the time of the fall R1's knee was swollen and R1 complained of pain yet medical attention was not sought,” according to the report. “Multiple interviews noted deformity in R1's leg on the days following the fall. Based on documentation and statements interviewed individuals, it was concluded that the resident fell on Feb. 24, 2020, complained of pain daily, observed with deformity to the hip/leg and medical attention was not sought until Feb. 27, 2020.”

Following the investigation’s findings an immediate civil penalty in the amount of $500 was assessed for a violation resulting in serious injury of a resident in care.

The other most recent substantiated complaint was from a complaint received on Feb. 19, 2019, alleging that the facility lacked sufficient staff to meet resident’s needs and that the facility staff failed to meet resident’s needs, similar concerns to Barton-Wren and Opferman’s.

According to the investigation, “Facility staffing schedule shows that in February 2019, Saturdays have one caregiver and one med tech scheduled in the assisted living part of the facility. Staff interviews (S1 & S2) verify the facility regularly schedules weekend shifts with one med-tech and one caregiver. Also, after review of record and interviews, the department found nine residents facility staff expressed had the ‘highest needs’ in the facility. (R1, R2, R3, R4, R5, R6, R7, R8, & R9). During February of 2019, one of the residents listed as having the highest needs, R2, is documented to need two person’s to assist them with transferring, and three of the nine residents (R1, R3, & R4) require ‘total assistance’ in ambulation, bathing, dressing, toileting and transfers.”

Licensing found a preponderance of evidence in the complaint to show that at the time there was a lack of sufficient staffing at the facility to meet the resident’s needs on Saturdays.

Interviews showed that resident’s care needs at the facility could not be met by two staff and found that if one staff on duty takes a break, there was only one staff able to meet resident needs at that time.

Recent complaints, future plans

Murray said there have not been any complaints filed under the new licensee applicant, Pacifica Senior Living Grove Inc., whose license is pending. 

When asked if the five substantiated complaints are considered to be a lot when looking at the history of a facility and if it’s concerning when a facility continues to get substantiated complaints Murray said, “There are over 7,000 licensed Residential Care Facilities for the Elderly (RCFEs) in the state. Making such comparisons can be difficult as each facility is unique.”

He did say, “Healdsburg Senior Living has one additional open complaint, which was received on Oct. 1, 2020. This complaint, which alleges numerous quality of care issues, is also under investigation.”

Murray said the Dec. 18, 2020 complaint is under investigation.

He said he cannot comment on an ongoing investigation. The department is conducting an investigation and cannot comment on ongoing investigations.

“The time it takes to complete investigations can vary greatly depending on many factors. Each complaint is unique, and each facility has a different capacity and population served. During investigations, the department works to gather factual evidence to determine if a violation has occurred. The department can, for example, work with police, medical personnel, neighbors, family members, friends and any other pertinent witnesses as needed during investigations. Investigations are concluded as substantiated when there is a preponderance of the evidence to prove that the alleged incidents occurred. Conversely, investigations are concluded as unsubstantiated when there is not a preponderance of the evidence to prove that the alleged incidents occurred. Upon completion of an investigation, if complaints are substantiated, the facility may face penalties ranging from a plan of correction to license revocation, depending on the severity of the substantiated complaints,” Murray said.

(3) comments

Prairie Dweller

Are Rob and Tony to there anymore? They were great.


I have heard they both are gone, unfortunately,


Terry (the head nurse - loved her!) left first, then Tony left December 15th (he had delayed his planned retirement for over 6 months) while Rob was on sabbatical, due back January 1st. Rob came back and turned in his resignation. Javier, a long-term employee, handyman, bus driver and all around great guy is also gone. Beth and Lynn, the super receptionists are still there, but who knows for how long. There are very few people left with whom I have a relationship and with COVID and the inability to get in to see how things are going, we are flying blind. Not a great feeling.

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