496803241-11-20-2023-21-AS-BMOS-CY2UAP-20231129142503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803241
Report Date: 11/20/2023
Date Signed: 11/20/2023 01:11:06 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
09/27/2023 and conducted by Evaluator Victoria Bertozzi

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230927100309

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: 98	DATE:	11/20/2023
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Robert Alvarado		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Insufficient Staffing
Facility is not ensuring that residents have incontinence supplies

INVESTIGATION FINDINGS:

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Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegations and met with Robert Alvarado. Administrator, Katelyn Ledesma was unavailable during this visit.

Insufficient Staffing - Complaint alleges that facility does not always have two caregivers to assist residents who need two people to transfer them. This allegation was supported by interviews and review of staff schedule indicating that staff do have shifts where they work by themselves.

Facility is not ensuring that residents have incontinence supplies - Complaint alleges that there are not always sufficient incontinence supplies for residents. This allegation is supported by interviews indicating that while there may be backup supplies sometimes, there are not always backup supplies resulting in caregivers using other residents' supplies which are not always replaced. It is facility policy that incontinence supplies

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: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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-20230927100309

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: 11/20/2023

NARRATIVE

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Continued from LIC9099

are not provided by the facility unless the resident has signed up to have facility obtain supplies. While some individuals were aware of facility protocol, which includes "express" delivery of supplies, not all staff were familiar with it.

Based on interviews which were conducted and document 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: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230927100309

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: 11/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/21/2023 Section Cited CCR 87411(a)	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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of	1 2 3 4 5 6 7	Facility agrees to submit a written plan indicating how they will ensure sufficient staffing at all times to meet the needs of residents who require a two-person assist no later than 11/21/2023.
	8 9 10 11 12 13 14	personal assistance and care as required in Section 87608, Postural Supports...This requirement was not been met as evidenced by interviews and record review showing that caregivers have worked by themselves despite residents requireing two-person assists. This is an immediate risk.	8 9 10 11 12 13 14
Type B 11/30/2023 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464 Basic Services A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457,	1 2 3 4 5 6 7	Facility agrees to provide training to staff regarding facility protocol to obtain incontinence supplies and submit proof of training to CCL no later than 11/30/2023.
	8 9 10 11 12 13 14	Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by interviews revelaing that there is not always incontinence supplies resulting in staff using supplies from other residents.	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: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

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