496803241-1-8-2024-21-AS-VBEI-CZMUKD-20240119143859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803241
Report Date: 01/08/2024
Date Signed: 01/08/2024 02:31:12 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/12/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20231212163014

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: 83	DATE:	01/08/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Business Office Manager, Danielle Oseguera		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Staff did not repair a resident's pull cord device
Staff did not respond timely to a resident's alerts

INVESTIGATION FINDINGS:

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At approximately 10:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Business Office Manager, Danielle Oseguera.

During the course of the investigation, LPA requested and reviewed documents, and conducted interviews. There are allegations that staff did not repair a resident's pull cord device and that staff do not respond timely to a resident's alerts. Based on record review and staff interviews, LPA confirmed that some resident pull cords are in need of repair/replacing and were not operable when tested by facility staff. Staff interviews conducted stated that the facility's call system occasionally does not work. Staff interviews stated that sometimes residents will call for assistance, but the call does not always show up on the care staff's pagers. Care staff have started to check the facility's computer to see if any calls are appearing since it does not always appear on their pagers.
Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

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-20231212163014

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE CHANATE	FACILITY NUMBER: 496803241
	VISIT DATE: 01/08/2024

NARRATIVE

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Continued from LIC9099

Review of facility call log records indicated that multiple residents have called for assistance and did not receive a response. Records also indicated that multiple residents have waited 30 minutes or longer for assistance. Based on record review and staff interviews, these allegations are Substantiated.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

**An Immediate Civil Penalty in the total amount of $500 is being assessed for repeat violations of Regulation 87411(a) and 87303(i) more than once in a 12 month period. (See LIC421IM)**

Exit interview conducted. Plan of Corrections reviewed and developed with Business Office Director. Copy of report, LIC9099D, LIC421IM, Plan of Corrections, and Appeal Rights discussed and provided to Business Office Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231212163014

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE CHANATE	FACILITY NUMBER: 496803241
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/08/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/09/2024 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. This requirement was not met as evidenced by: based on record review, the Licensee did not comply with	1 2 3 4 5 6 7	Licensee to submit a written plan outlining how resident care needs will be met when all or part of the facility's signal system is inoperable. Plan to be submitted by POC due date, 01/09/2024.
	8 9 10 11 12 13 14	the section cited above. Multiple call records showed that residents waited for at least 30 minutes or longer to receive assistance from care staff or did not receive assistance at all. This poses an immediate health, safety or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type A 01/09/2024 Section Cited CCR 87303(i)	1 2 3 4 5 6 7	87303 Maintenance&Operation (i) Facilities shall have signal systems...:(1)All facilities licensed for 16 or more...(A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce... signal...loud enough to summon staff. This requirement	1 2 3 4 5 6 7	Licensee to submit a written plan/protocol on how facility will ensure that their signal system equipment remains operable. Facility to also outline how resident care will be maintained and responded to timely by care staff. Plan/protocol to be submitted by POC due date of 01/09/2024.
	8 9 10 11 12 13 14	was not met as evidenced by: based record review and interviews conducted, Licensee did not comply with section cited above. Facility call cords need replacement and pagers don't always indicate resident calls. This poses an immediate health, safety or personal rights risk to residents in care.	8 9 10 11 12 13 14	Licensee to conduct In-service training on facility plan/policy with all care staff. In-service Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date of 01/18/2024.

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC9099 (FAS) - (06/04)

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