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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802025
Report Date: 02/15/2024
Date Signed: 02/15/2024 10:25:04 AM


Document Has Been Signed on 02/15/2024 10:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 55DATE:
02/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Health and Wellness Director, Tina WordenTIME COMPLETED:
10:35 AM
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At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit and met with Health and Wellness Director, Tina Worden. The purpose of today's visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL).

SOC-341 Report 1: CCL received an SOC-341 on 12/08/2023. Report stated possible suspicion of financial abuse. Facility found that Resident 1 (R1) was found to be missing $140 on 12/08/2023. R1's Responsible Party also reported to Facility that $1700 had been missing from R1's room approximately 3 months prior to report.

SOC-341 Report 2: CCL received an SOC-341 on 01/02/2024. Report stated possible suspicion of financial abuse. It was reported that Resident 2 (R2) was missing money and other items from their room. Facility was informed by R2's Responsible Party on 12/28/2023, it was discovered that $580, bag of jewelry, and a blanket were missing from R2's room.

Facility made all appropriate notifications per regulation. Facility has continued to communicate with Responsible Parties regarding theft. Facility intends on conducting a Town Hall meeting to address theft prevention measures.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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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