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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802025
Report Date: 11/17/2023
Date Signed: 11/17/2023 12:35:23 PM


Document Has Been Signed on 11/17/2023 12:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:BROOKDALE WINDSORFACILITY NUMBER:
496802025
ADMINISTRATOR:KINNEY, JEANNETTEFACILITY TYPE:
740
ADDRESS:907 ADELE DRTELEPHONE:
(707) 837-8785
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:80CENSUS: 50DATE:
11/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:Administrator, Jeannette KinneyTIME COMPLETED:
12:45 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Jeanette Kinney.

LPA is following up regarding a self-reported incident where a staff allegedly violated the personal rights of a resident in care. Per Administrator, they are conducting an internal investigation regarding the allegation but have not yet come to a determination. The involved staff is currently on leave pending the outcome of the investigation. Facility has cross-reported incident per mandatory reporting requirements.

LPA conducted interviews and will obtain additional information.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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