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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803241
Report Date: 02/23/2022
Date Signed: 02/23/2022 10:51:50 AM


Document Has Been Signed on 02/23/2022 10:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 72DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director/Administrator, Maria CortesTIME COMPLETED:
11:01 AM
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At approximately 9:00AM, Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced to conduct an Annual required Inspection and met with Administrator, Maria Cortes. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPAs temperatures were checked and documented. LPAs conducted a walk-through of the facility and observed the following: Facility had face mask posters throughout the facility including at the entry way and hand washing signs in the bathroom. LPAs discussed with Administrator to add more signs regarding social distancing and cough etiquette. Based on review of Staff Temperature Log, staff have not documented their COVID-19 screenings for today. Administrator was reminded that staff are to screen at the beginning of each shift. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was available in common areas. LPAs observed staff wearing masks during this visit. Residents are encouraged to wear masks while in common areas. Commonly touched surfaces are disinfected three times a day by housekeeping and caregivers on Noc Shift. LPAs confirmed that housekeeping in Assisted Living works 7 days/week and Housekeeping in Memory Care works 5 days/week. Caregivers in Memory Care sanitize when Housekeeping is unavailable.

LPAs and Administrator discussed resident activities and visitation.

Continued on LIC809C.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BROOKDALE CHANATE
FACILITY NUMBER: 496803241
VISIT DATE: 02/23/2022
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Continued from LIC809.

Facility has at least a 30 day supply of Personal Protective Equipment (PPE) including surgical masks, gloves, gowns, and hand sanitizer.

Per conversation with Maintenance Director, Fire Extinguishers were serviced within the last month however the tags were not updated. Maintenance Director will follow up. Service logs for fire alarms and carbon monoxide detectors were reviewed.


LPAs followed up on 3 incident reports where residents passed away but were not on Hospice.

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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