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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802025
Report Date: 02/08/2022
Date Signed: 02/08/2022 12:11:52 PM

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:WATSON, WENDYFACILITY TYPE:
740
ADDRESS:907 ADELE DRTELEPHONE:
(707) 837-8785
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:80CENSUS: 55DATE:
02/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Licensee, Wendy WatsonTIME COMPLETED:
12:21 PM
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Licensing Program Analyst Willis arrived unannounced to conduct a Case Management inspection and met with Administrator, Wendy Watson.

LPA is following up on two self-reported incidents involving residents, R1 and R2.

Resident, R1 had an un-witnessed fall on December 8, 2021 resulting in an injury that caused resident to be admitted into the hospital. Resident declined surgical repair and returned to the facility on hospice.

Resident, R2 had an un-witnessed fall on January 2. 2022. Per staff interview and incident report, R2 refused to go to the hospital despite facility staff offering multiple times. Due to increased pain, resident did go to the hospital on December 7, 2022 where they were diagnosed with a fracture. Resident has returned to the facility and is receiving follow-up care

Based on file review and interview, neither resident required one-to-one assistance.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
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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