The Ridges at Healdsburg

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...: (1) A written report shall be submitted to the licensing agency... within seven days... (B) Any serious injury...resident is under facility supervision. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in that an LIC 624 Unusual Incident Injury report for resident R1 was filed with Community Care Licensing (CCL) on 1/5/2026 for an injury that occurred on 12/10/2025 which poses a potential health, safety or personal rights risk to persons in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews photographic evidence, record review and express admission the licensee did not comply with the section cited above in that the facility did not properly repair a leak in a hot pex line in Memory Care 2, room #10 which posed an immediate health, safety or personal rights risk to persons in care.

Based on observation & record review, the licensee did not comply with the section cited above in that two (2) of eight (8) residents files (for residents R1 & R2) have not had an annual routine visit with a licensed medical professional which poses a potential health, safety or personal rights risk to persons in care.

87411Personnel Requirements-General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff...This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above in that lack of sufficient staffing prevented resident R1 to be repositioned which caused resident R1 to develop a stage 2 pressure wound which poses an immediate health, safety or personal rights risk to persons in care.

Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by Based on record review and interviews the licensee did not comply with the section cited above in that staffing in AL is not sufficient per resident care needs including but not limited to requiring a two person assist, which poses a immediate health, safety or personal rights risk to persons in care.

87506 Resident Records (e)Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in that the facility did not retain R1’s original records or photographic reproductions which poses a potential health, safety or personal rights risk to persons in care.

87303 Maintenance and Operation(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that there was open access to the building under construction and various hazards therein, which poses an immediate health, safety or personal rights risk to persons in care.

Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by Based on record review and interviews the licensee did not comply with the section cited above in that staffing in MC1,MC2 & AL is not sufficient per resident care needs including but not limited to requiring a two person assist, which poses a immediate health, safety or personal rights risk to persons in care.

1569.625 Staff training... (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement was not met by licensee as evidenced by:Based on LPA record review, the licensee did not comply with the section cited above in that Staff Member S1 did not complete the one hour (1) monthly training for 5/2025 & 6/2025 as required by the Stipulation and Waiver; and Order dated, 6/30/2022 which poses an potential health, safety or personal rights risk to persons in care.

Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by Based on record review and interviews the licensee did not comply with the section cited above in that staffing in MC2 & AL is not sufficient per resident care needs including but not limited to requiring a two person assist, which poses a immediate health, safety or personal rights risk to persons in care.

Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: Based on LPA and Admin record review, the licensee did not comply with the section cited above in that staffing in MC1 and MC2 is not sufficient per resident care needs requiring a two person assist, which poses a immediate health, safety or personal rights risk to persons in care.

In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order... This requirement not met by licensee as evidenced by: Based on LPAs review of Monthly Quality Assurance Audit per stipulation dated 1/31/2025 & 2/26/2025, Licensee did not create a monthly activity calendar for Memory Care, which poses an potential health, safety or personal rights risk to persons in care.

Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger... This requirement not met by licensee as evidenced by: Based on LPAs review of Monthly Quality Assurance Audit per stipulation dated 5/2/2025 in Dementia Care, scissors were stored on the outside of the medicine care in Memory Care building two (2) which poses an immediate health, safety or personal rights risk to persons in care.

Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor...established procedures or which are otherwise to be disposed of shall be destroyed ...This requirement not met by licensee as evidenced by: Based on LPAs review of Monthly Quality Assurance Audit per stipulation dated 5/1/2025, Licensee did not ensure discontinued medications were destroyed, which poses an potential health, safety or personal rights risk to persons in care.

All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food...shall be stored in covered containers at appropriate temperatures. This requirement not met by licensee as evidenced by: Based on LPAs review of Monthly Quality Assurance Audit per stipulation dated 2/27/2025, food products were not covered or marked with an expiration date, which poses an immediate health, safety or personal rights risk to persons in care.

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPA and Admin toured the kitchen and observed the following food items not covered or not labeled with date: cart with cakes, bowls of a bread-like food item, and slices of pie, which poses an immediate health, safety or personal rights risk to persons in care.

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty... This requirement is not met as evidenced by: Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S3 ands S4 did not have current CPR on file, which poses an immedisate health, safety or personal rights risk to persons in care.

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S4 and S6 do not have complete required training on file, which poses an immediate health, safety or personal rights risk to persons in care.

§1569.625 Staff training... (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement was not met by licensee as evidenced by: Based on LPA and Admin record review, the licensee did not comply with the section cited above in that seven out of seven staff files reviewed, staff did not have the required hours of annual training completed, which poses an immediate health, safety or personal rights risk to persons in care.

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that the following food items were not covered and/or not labeled with date: cart with cakes, bowls of a bread-like food item, and slices of pie, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed box of lettuce and lettuce actively being used to prepare salads to have black wilted leaf tips and/or stalks. Some the the leaf tips were both black and had a white fuzzy substance present, which poses a potential health, safety or personal rights risk to persons in care.

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: 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.

Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S3, S4, S5 and S6 did not have current CPR on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above inthat S4 and S6 do not have complete required training on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that pendant system not repsonding correctly to calls/pages when R2's pendant pressed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA observation and record review, the licensee did not comply with the section cited above in that an entry for an Olanzapine 2.5 mg prescription filled on 12/7/24 for R1 was missing from the Centrally Stored Medication Log which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA observation, the licensee did not comply with the section cited above in that Some food items observed were not covered or not labeled with date of opening: chocolate mousse, cakes, and dishes of fruit, gallon of milk and white food item that looked like mashed potatoes or riced cauliflower, which poses a potential health, safety or personal rights risk to persons in care.

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia (2) Over-the-counter medication, nutritional supplements or vitamins... and toxic substances such as certain plants.... and disinfectants. This requirement was not met by licensee as evidenced by: QA audit report indicated medications found in resident rooms and creams/lotions left out in resident rooms, which poses a potential health, safety or personal rights risk to persons in care.

87468.2 Additional Personal Rights...(a) In addition to the rights listed in Section 87468.1... residents... shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility. This requirement was not met by licensee as evidenced by: Based on LPA interviews and record review, facility does not have adequate number of direct care staff In Memory Care building #1 to support each resident’s physical, social, emotional, safety, and health care needs as identified in their current appraisal/care plan and/or physician's report, such that they can make choices concerning their daily lives in the facility, which poses a potential health, safety or personal rights risk to persons in care.

§1569.269 Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, the licensee did not comply with the section cited above in that between 9/1/2024 and 9/27/2024 residents pushed their pendant call button at least 621 times. Of those 621 times at least 126 either never got a response or there was an error in the pendant log system, which poses a potential health, safety or personal rights risk to persons in care.

§1569.625 Staff training... (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement was not met by licensee as evidenced by: Based on LPA record review, the licensee did not comply with the section cited above in that seven out of seven staff files reviewed, staff did not have the required hours of annual training completed, which poses a potential health, safety or personal rights risk to persons in care.

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: Based on LPA interviews and record review, facility does not have adequate number of direct care staff In Memory Care building #1 to support each resident’s physical, social, emotional, safety, and health care needs as identified in their current appraisal/care plan and/or physician's report, which poses a potential health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (a) A plan for incidental medical & dental care shall be developed by each facility. Plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by R1 being given incorrect medication which poses an immediate health & safety risk to residents.

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care & supervision as defined in...Health and Safety Code section 1569.2(c). Health & Safety Code section 1569.2(c) provides: (c) "Care & supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Requirement was not met as evidenced by resident eloping the facility. This is an immediate Health & Safety risk.

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by file review and interview showing that R1 missed their medication for multiple days due to facility error which is an immediate risk to the health and safety of residents in care.

Based on observation, the licensee did not comply with the section cited above by having disinfectants accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.