496803241-6-11-2024-21-AS-VBEI-D6DM3W-20240619091545

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803241
Report Date: 06/11/2024
Date Signed: 06/11/2024 09:20:58 AM

Unsubstantiated

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
01/18/2024 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20240118085437

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: 94	DATE:	06/11/2024
		UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Health and Wellness Director, Heidi Gallagher, and Interim Executive Director, Alex Baiasu		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff are not following a resident's needs and services plan

INVESTIGATION FINDINGS:

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At approximately 8:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Health and Wellness Director, Heidi Gallagher, and Interim Executive Director, Alex Baiasu.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff are not following a resident’s needs and services plan.” Complainant alleged that facility did not follow Resident 1 (R1’s) care plan by not changing or rotating them enough and stated that facility staff were to change and rotate R1 every two hours. Review of R1’s file indicated that they were admitted to Hospice on 12/26/2023. Review of R1’s Personal Service Plan, dated 01/04/2024, stated R1 was to be checked and changed approximately every 3 to 4 hours.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

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-20240118085437

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: 06/11/2024

NARRATIVE

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Continued from LIC9099

LPA conducted interviews with involved parties and received inconsistent statements. Interviews with facility staff stated that they would come in to change and rotate R1 but that R1’s family would refuse to have care done. Interviews conducted with R1’s Hospice Provider stated that they saw facility staff come into R1’s room to see if R1 needed care services. Per Hospice Provider, they did not witness facility staff provide care services during their visits and believed that facility staff would wait until Hospice left to change and rotate R1. Per R1’s Hospice Provider, they did not have concerns regarding the care being provided by the facility as R1’s pressure injuries showed improvement. Review of R1’s records dated 01/18/2024, showed that R1’s stage 3 pressure injuries had improved. Review of Hospice Collaboration notes dated 01/05/2024 and 01/09/2024 corroborated that R1’s pressure injuries were improving. Review of Facility Shift Reports dated 12/14/2023, 12/17/2023, 12/21/2023, 01/01/2024, 01/02/2024, 01/03/2024, 01/10/2024, 01/11/2024, 01/14/2024, 01/17/2024, 01/18/2024, and 01/19/2024 showed when R1 was checked, changed and rotated, and when family would refuse care. Interview conducted with R1’s Responsible Party stated that there were a few days when they observed that R1 was not checked by facility staff for 8 to 16 hours, and that they changed and rotated R1 because facility staff did not do it. Per interview, care services were never refused. R1’s Responsible Party also stated that they observed facility staff come in more frequently to check on R1.

Based on record review and inconsistent statements provided during interviews, the LPA is unable to determine if violations occurred. Therefore, the allegation is Unsubstantiated. A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Health and Wellness Director, and Interim Executive Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC9099 (FAS) - (06/04)

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