496802025-10-21-2022-21-AS-CMAZ-CKMTTT-20221028150115

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496802025
Report Date: 10/21/2022
Date Signed: 10/21/2022 02:58:46 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/03/2022 and conducted by Evaluator Victoria Bertozzi

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20221003165450

FACILITY NAME:	BROOKDALE WINDSOR		FACILITY NUMBER:	496802025
ADMINISTRATOR:	WATSON, WENDY		FACILITY TYPE:	740
ADDRESS:	907 ADELE DR		TELEPHONE:	(707) 837-8785
CITY:	WINDSOR	STATE: CA	ZIP CODE:	95492
CAPACITY:	80	CENSUS: 51	DATE:	10/21/2022
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Administrator, Wendy Watson		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Questionable Death(s)
Staff did not seek medical attention for resident(s) in care in a timely manner
Staff did not report incident(s) involving resident(s) in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegations and met with Administrator, Wendy Watson.

During investigation LPA conducted interviews, made observations and reviewed documents. Complaint alleges that multiple residents died after someone in the kitchen accidently gave them chemicals instead of juice. Per complaint, staff did not call an ambulance or the police for 1.5 hours despite resident(s) exhibiting signs of pain and distress. Complaint alleges that the incident was never reported to licensing. Interviews conducted do not support that this incident occured at this facility and interview with witness revealed that they assumed the alleged incident occurred at this facility based on the information they were provided. LPA was provided limited details of the alleged incident and the details provided were not supported by other evidence. Interviews with staff denied that this alleged incident happened at this facility.

Continued on LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20221003165450

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BROOKDALE WINDSOR	FACILITY NUMBER: 496802025
	VISIT DATE: 10/21/2022

NARRATIVE

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Continued from LIC9099

The logs provided by the police show that they did not respond to the facility regarding the alleged incident as reported and have not responded to any incident at the facility within the referenced time frame.

Administrator provided LPA a list of all residents who left the facility in September 2022. Two residents were identified as having passed away and LPA was provided reports of their passing at that time. Neither resident was identified as passing away from ingesting chemicals.

LPA observation of cleaning supplies in the kitchen showed that chemicals used for cleaning are stored in a separate room and hoses from the containers are fed to the kitchen sinks through the hoses. Juice containers are loaded into a machine and then dispensed from the machine. Juice and chemicals are stored separately.

This agency has investigated the complaints alleging questionable death(s), that staff did not seek medical attention for resident(s) in care in a timely manner and that staff did not report incident(s) involving resident(s) in care. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

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