496803241-3-19-2024-21-AS-CCOO-D3J23Y-20240319170308

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803241
Report Date: 03/19/2024
Date Signed: 03/19/2024 05:03:17 PM

Document Has Been Signed on 03/19/2024 05:03 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 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: 88	DATE:	03/19/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:27 PM
MET WITH:	Heidi Gallagher, Health and Wellness Director		TIME COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 1:30pm Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management pertaining to Incident Reports received by CCL on 2/15/2024 and 2/20/2024, respectively. Upon LPA arrival LPA learned that there is not a current Administrator or Executive Director. LPA was advised that a corporate representative is here in the interim of hiring a replacement for Katelyn Ledesma. The corporate representative is Operations Specialist Dimple Kamdar and their Administrator Certificate is # 6027505740, expired 7/2021; however, they are currently in renewal status as of 8/22/2023. LPA discussed with Operations Specialist the need for corporate to have an Administrator at all times. Per Title 22 regulation 87405(a) All facilities shall have a qualified and currently certified administrator. LPA advised Kamdar, should an Administrator quit or be released from duty, CCL must be notified within 30 days. Also, once the replacement candidate is chosen, the required documentation must be sent to CCL for review and approval. LPA will follow up and discuss the requirements with the Brookdale corporate representative. As pertains to Incident Report received by CCL on 2/15/2024, on 2/7/2024 resident (R1) was sent to Kaiser and returned to facility on 2/13/2024 at 1:00pm. R1 was placed on hospice while in the hospital. R1 is their own responsible party. R1 returned to facility with their family member who was using combative language with staff and using profane language. Family member was refusing to let any staff in R1's room, claiming they will take care of administering R1's pain management medications per R1's hospice care plan. Facility Health and Wellness Director (HWD) was immediately informed by attending med tech as to the aforementioned. Per LPA review of charting notes, a check was performed by staff every hour on the hour in order to gain access to R1 and attend to their care needs. At each instance staff were met with combative and profane language by R1's family member. HWD worked with hospice nurse to administer R1's pain management medications, despite the effort of R1's family member to deny staff access to R1. Hospice nurse was successful in administering pain management medication. Between the hours of 1:00pm on 2/13/2024 and 9:30pm on 2/14/2024 staff attempted to provide care to R1 ten times, per LPA review of charting notes. R1 passed on 2/14/2024 at approximately 10:15pm. Continued on 809C...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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: 03/19/2024

NARRATIVE

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Continued from 809...

LPA discussed with Operations Manager and HWD implementing a plan going forward on how they will address situations in which staff providing care to residents is denied or blocked. Facility to implement a plan to maintain compliance with Title 22 regulation 87411(a) 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. Facility to submit written plan implemented in either the Plan Of Operation, the residents' Admission Agreements, or residents' Care Plans and submitted to CCL no later than 4/5/2024.

As pertains to Incident Report received 2/20/2024, on 2/8/2024 resident (R2) was taken to a routine podiatrist appointment at which the podiatrist suspected that R2 had osteomyelitis and needed to have EMS transport to ER for surgery. Per incident report, resident was transported back to the facility and then EMS services were called to transport R2 for surgery. R2 was returned to facility at the refusal of the podiatrist to call EMS services, per HWD this is not the policy of the facility. Per LPA review of charting notes, care plan, LIC602, and pre-placement appraisal R2's need for care related to feet not present. R2's preplacement appraisal indicated one amputated toe; per LPA interview with HWD R2 was admitted with contracted toes. LPA discussed with Kamdar adding additional observation of R2's feet to care plan in order to ensure that proper attention and care is given and ensure resident's feet are being properly assessed. Any potential issues need to be addressed in a timely manner. All residents' care needs are to be addressed in their appraisal and/or care plan.

No deficiencies cited.

Exit interview conducted with Operations Specialist and a copy of this report was given.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

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