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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802025
Report Date: 06/06/2023
Date Signed: 06/06/2023 12:59:04 PM


Document Has Been Signed on 06/06/2023 12:59 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:WATSON, WENDYFACILITY TYPE:
740
ADDRESS:907 ADELE DRTELEPHONE:
(707) 837-8785
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:80CENSUS: 42DATE:
06/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Administrator, Brandee RodriguezTIME COMPLETED:
01:08 PM
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Licensing Program Analyst (LPA) Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Brandee Rodriguez.

Facility submitted reports regarding resident, R1 who was recently discharged from hospice services. Per reports resident was found on the floor by staff. Resident denied pain and/or hitting their head. Later, when resident started complaining of pain, they were transported to the hospital. Resident passed away at the hospital three days later. Per file review, resident did not require 1:1 supervision.

Facility has requested the Death Certificate. Once received, facility will send a copy to the Department.

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: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
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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