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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802025
Report Date: 10/03/2023
Date Signed: 10/03/2023 03:37:37 PM


Document Has Been Signed on 10/03/2023 03:37 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:
10/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Administrator, Jeannette KinneyTIME COMPLETED:
03:45 PM
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Licensing Program Analysts Bertozzi and Coppo arrived unannounced to complete a case management inspection. LPAs met with Executive Director Jeannette Kinney.

LPAs requested and reviewed resident files for two residents. LPAs are following up on self-reported incident report for R1. Per incident report resident was transported to the hospital following a positive COVID diagnosis and because of additional health concerns. LPAs reviewed resident's care plan which indicated that the facility's health concerns were documented in R1's care plan. Additionally, the resident was under the care of a third party home health care agency.

Per special incident report R2 recently fell on bathroom floor, resulting in a head laceration and fracture. Incident report indicates resident was confused and vomiting. R2 was sent to the hospital 9/11/2023 and later passed away. Resident did not need one to one supervision per their care plan.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
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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