496803241-11-6-2023-21-AS-CMAZ-D7BUL8-20240719154014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803241
Report Date: 11/06/2023
Date Signed: 11/06/2023 03:43:03 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
09/21/2023 and conducted by Evaluator Victoria Bertozzi

COMPLAINT CONTROL NUMBER: 21-AS-20230921102025

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: 103	DATE:	11/06/2023
		UNANNOUNCED	TIME BEGAN:	01:19 PM
MET WITH:	Administrator, Katelyn Ledesma.		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not provide written incident report to responsible party

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and met with Administrator, Katelyn Ledesma.

Facility did not provide written incident report to responsible party - Complaint alleges that facility did not provide the resident's death report to their responsible party. Interviews revealed that facility did not provide report because the facility was unable to determine whether the responsible party had authority to receive the report. LPA's review of R1's Admission Agreement and interviews revealed that the death report was not provided to the individual who signed the Admission Agreement.

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: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 21-AS-20230921102025

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: 11/06/2023

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
26
27
28
29
30
31
32

Continued from LIC9099

Health and Safety Code 1569.880 requires that Admission Agreements are signed by the resident or their representative indicating that the individual who signed the resident's Admission Agreement is their representative/responsible party so should have been provided the death report per Regulation 87211 Reporting Requirements

Based on interviews which were conducted and record 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: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20230921102025

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: 11/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/10/2023 Section Cited CCR 87211(a)(1)(A)	1 2 3 4 5 6 7	87211 Reporting Requirement (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following: (1) A written report shall be submitted to the licensing agency & to person responsible for the resident within 7 days of the occurrence of any of the	1 2 3 4 5 6 7	Facility to submit self-certification that they have provided the death report to R1's responsible party/representative no later than 11/10/2023
	8 9 10 11 12 13 14	events specified in (A) through (D) below...(A) Death of any resident from any cause regardless of where the death occurred... Licensee didn't meet requirement as evidenced by: Based on interviews & document review death report was not provided to responsible person.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4