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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801588
Report Date: 11/17/2021
Date Signed: 11/17/2021 10:00:46 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2021 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20211109093144
FACILITY NAME:CHANATE CARE HOMEFACILITY NUMBER:
496801588
ADMINISTRATOR:CREDO, JOSEPHINEFACILITY TYPE:
740
ADDRESS:3615 CHANATE RD.TELEPHONE:
(707) 526-4153
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:5CENSUS: 5DATE:
11/17/2021
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator, Josephine Credo-AlconesTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Resident eloped from the facility
Staff have not reported resident eloping in a timely manner
Staff have not reported incident to authorized representatives
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrived unannounced to conduct a complaint investigation regarding the above-mentioned allegations and met with Administrator, Josephine Credo-Alcones.

During investigation, LPA conducted interviews, made observations and reviewed documents.

Resident eloped from the facility – Based on two police reports, one Special Incident Report and interviews, LPA confirmed that resident, R1 eloped the facility twice and was brought back to the facility by the responsible party and police.

Staff have not reported eloping in a timely manner – Based on interviews, resident’s responsible party was not notified of their elopement within the timeframe required by regulation. Per Administrator, they notified the resident's responsible party two days after the second elopement. Another interview indicated it was eight days after the incident that the responsible party was notified.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20211109093144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: CHANATE CARE HOME
FACILITY NUMBER: 496801588
VISIT DATE: 11/17/2021
NARRATIVE
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Continued from LIC9099

Staff have not reported incident to authorized representatives – CCL was notified of the second elopement 13 days after it occurred, in writing. A Special Incident Report was not received by CCL after the first elopement but during this visit Administrator provided the special incident report along with proof that they faxed the report to CCL the day after the elopement.

The allegations that Resident eloped from the facility, Staff have not reported resident eloping in a timely manner, and staff have not reported incident to authorized representatives are Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20211109093144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CHANATE CARE HOME
FACILITY NUMBER: 496801588
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited
CCR
874511(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement has not been met as evidenced by: Based on interview and reports the licensee did not comply with the section cited above because resident
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Licensee to submit their elopement protocol and proof that staff have been trained on protocol to CCL by POC due date, 11/18/2021.
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eloped facility twice. This is an immediate risk to the health and safety of residents in care.
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Type B
11/18/2021
Section Cited
CCR
87705(k)(7)
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87705 Care of Persons with Dementia - For each incident in which a resident wanders away from the facility unsupervised, the licensee shall report the incident to the licensing agency, the resident’s conservator and/or other responsible person, if any, and to any family member who has requested notification. The report shall be made
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Licensee to submit self-certification that they have read and understand regulation 87705 to CCL by POC due date, 11/19/2021.
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by telephone no later than the next working day and in writing within 7 calendar days. Based on interview and reports the licensee did not comply with the section cited above because CCL and the responsible party were not notified within the time frame and manner specified in regulation. This is a potential risk to the health & safety of residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2021 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20211109093144

FACILITY NAME:CHANATE CARE HOMEFACILITY NUMBER:
496801588
ADMINISTRATOR:CREDO, JOSEPHINEFACILITY TYPE:
740
ADDRESS:3615 CHANATE RD.TELEPHONE:
(707) 526-4153
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:5CENSUS: 5DATE:
11/17/2021
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator, Josephine Credo-AlconesTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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The facility door alarms are not working
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrived unannounced to conduct a complaint investigation regarding the above-mentioned allegations and met with Administrator, Josephine Credo-Alcones.

During investigation, LPA conducted interviews, made observations and reviewed documents.
The facility door alarms are not working – Incident Report provided by the facility attributes the second elopement to have occurred because the resident followed a home health nurse out of the facility and staff assumed the door alarm was from the nurse leaving so did not check on it. Other interviews indicated that the alarms had been malfunctioning. Interview with Administrator indicated that the first elopement occurred because the alarms were not loud enough. Administrator has since installed louder alarms and have provided additional training to staff.
A finding that the complaint allegation that the facility door alarms are not working was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred.

No deficiencies cited.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4