496803241-10-23-2023-21-AS-BMOS-CX6TC3-20231101143602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803241
Report Date: 10/23/2023
Date Signed: 10/23/2023 04:50:40 PM

Substantiated

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
09/14/2023 and conducted by Evaluator Victoria Bertozzi

COMPLAINT CONTROL NUMBER: 21-AS-20230914133321

FACILITY NAME:	BROOKDALE CHANATE		FACILITY NUMBER:	496803241
ADMINISTRATOR:	LEDESMA, KATELYN		FACILITY TYPE:	740
ADDRESS:	3250 CHANATE RD		TELEPHONE:	(707) 575-7503
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY:	140	CENSUS: 103	DATE:	10/23/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Health and Wellness Director, Heidi Gallagher		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Residents' pendants are not working
Staff do not help residents in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst Victoria Bertozzi arrived unannounced to deliver findings regarding the above complaint allegations and met with Health and Wellness Director, Heidi Gallagher.

During investigation LPA conducted interviews with staff, residents and other interested parties, reviewed documents and made observations.

Residents' pendants are not working - Complaint alleges that the call bell system that includes the pendants was not working for multiple weeks. LPA confirmed through multiple staff and resident interviews that the call button system was down for multiple weeks. Facility has since had system repaired.

Continued on LIC9099C

Substantiated

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: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

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-20230914133321

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 CHANATE	FACILITY NUMBER: 496803241
	VISIT DATE: 10/23/2023

NARRATIVE

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Continued from LIC9099

Staff do not help residents in a timely manner - Complaint alleges that because the call button system was not functioning, residents did not receive help in a timely manner. Per interviews, residents were to be checked every two hours when the call button system was not working though interviews revealed that staff were not always able to meet that timeline resulting in at least one resident not having their needs met timely.

Based on interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230914133321

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 CHANATE	FACILITY NUMBER: 496803241
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/24/2023 Section Cited CCR 87411	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Licensee did not meet this requirement based on interviews that confirm not all resident's needs were met timely due	1 2 3 4 5 6 7	Administrator to provide CCL the written facility policy and/or protocol regarding how resident's needs are met when all or part of the signal system is inoperable and how resident's needs are met during those times by POC due date, 10/24/2023.
	8 9 10 11 12 13 14	to the signal system being down and staff not being able to supervise per stated protocol. This is an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
Type B 10/24/2023 Section Cited CCR 87303(i)	1 2 3 4 5 6 7	87303 Maintenance&Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit	1 2 3 4 5 6 7	Signal system has been repaired. Deficiency is cleared.
	8 9 10 11 12 13 14	a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. Requirement not met based on interviews indicating signal system was inoperable for multiple weeks.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

LIC9099 (FAS) - (06/04)

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