complaint·January 9, 2026

...Continued from 9099 LPA requested and was sent un-redacted emergency response documents from the City of Healdsburg Fire Department who responded to the facility’s 911 call. Additionally, the Fire Department sent photographs of the collapsed ceiling. The Fire Department report stated, “The piece of Sheetrock was approximately 3 foot by three foot square and upon further inspection looked as though it was inappropriately attached to the structural members where there was also a bucket up in the rafters which looked as if it were placed there to collect water from a roof leak. Medic 681 assisted the patient onto the gurney, and they were later transported to the hospital for evaluation and treatment of lacerations.” Noted sustained injuries are consistent with the after-visit summary provided by the hospital’s emergency department. Further inter-departmental emails from the Healdsburg Fire Department member HFD1 state, “the work that was done to hole up the section of dry wall looks to be poorly done.” Post accident repair invoices note, “fixed leak on ¾” hot pex line in ceiling,”. During staff interviews when asked when they first heard about the leak in the ceiling in room ten (10), a staff member stated, “for some time now, it would be leaking, then fixed, leaking then fixed.” In another interview when asked what was done to mitigate the potential for injury to the residents, a staff member stated, “we put a container underneath (the leak) to catch water.” Additionally, during an interview a staff member stated, “it was our fault the bucket fell”. Based on LPA’s interviews, photographic evidence, record review and express admission, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. As this repeat deficiency occurred within one (1) year of the previous citation, a Civil Penalty of $250.00 will be assessed. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty. Exit interview conducted. Copy of LIC-9099, LIC-9099C, LIC9099D, LIC421FC, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Executive Director Interim Burton . Signature on form confirms receipt of documents.