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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803241
Report Date: 03/17/2023
Date Signed: 03/17/2023 03:29:29 PM


Document Has Been Signed on 03/17/2023 03:29 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 CHANATEFACILITY NUMBER:
496803241
ADMINISTRATOR:CORTES, MARIAFACILITY TYPE:
740
ADDRESS:3250 CHANATE RDTELEPHONE:
(707) 575-7503
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:140CENSUS: 81DATE:
03/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Maria Cortes, AdministratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Administrator, Maria Cortes.

Upon arrival, LPA observed that staff continue to wear masks per current guidance. LPA initiated a tour of the facility around 9:30am and made the following observations: Tour included Assisted Living Apartments, the Memory Care Unit, kitchen, dining room, various common areas for residents and offices used primarily by staff. Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in various sinks accessible to residents in care measured at 105, 105, 109 and 111 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cleaning supplies are locked in supply closets as well as mobile housekeeping carts. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked in both medication rooms.

Fire extinguishers were last serviced February 2023. Facility has hardwired combination Smoke/Carbon Monoxide detectors located throughout the facility that are maintained by a vendor and the most recent service was conducted October 2022. Most recent fire/disaster drill was conducted January 2023.

Six staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator Maria Cortes 6051451740 expired 3/13/2023 but has sent in their renewal paperwork. LPA reviewed proof that paperwork was submitted to Community Care Licensing and will continue to monitor. Medications and medication records were reviewed.

Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 CHANATE
FACILITY NUMBER: 496803241
VISIT DATE: 03/17/2023
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Continued from LIC809

Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit updates of the following documents by 4/17/2023:


LIC 500 Personnel Summary
Liability Insurance

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: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC809 (FAS) - (06/04)
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