496803241-7-11-2024-21-AS-CMAZ-D7BUL7-20240719154014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803241
Report Date: 07/11/2024
Date Signed: 07/11/2024 03:24:23 PM

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
09/21/2023 and conducted by Evaluator Christi Coppo

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: 97	DATE:	07/11/2024
		UNANNOUNCED	TIME BEGAN:	01:44 PM
MET WITH:	Heidi Gallagher, Director of Health and Wellness		TIME COMPLETED:	03:39 PM

ALLEGATION(S):

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Facility did not notify responsible party of resident's change of condition
Facility did not seek timely medical for resident in care

INVESTIGATION FINDINGS:

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At approximately 1:45pm, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with Heidi Gallagher, Director of Health and Wellness (DHW). Temporary Administrator Alex Baiasu contacted by phone and gave permission for DHW to sign.

During investigation, the Department conducted interviews and reviewed documents including, but not limited to, medical records and facility records.

Facility did not notify responsible party of resident's change of condition, Facility did not seek timely medical for resident in care - Complaint alleges that prior to their passing, resident, R1 had stopped eating for 5 days and had been refusing medications as well but the responsible party was not notified, and facility did not seek timely medical care.

Continued on 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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-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: 07/11/2024

NARRATIVE

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Continued from 9099...

Progress notes reviewed as part of the investigation show that resident was eating less food and refusing medications due to the pills being too large to swallow. Resident’s doctor was faxed to request an order for pill crushing. Per staff interviews, resident had been on a decline for approximately one year and showed signs of a low appetite in addition to refusing medication. Due to resident already declining, there was no identified change of condition which warranted further medical intervention.

Per evidence obtained during investigation, on the day that resident passed away they requested Tylenol due to complaints of a headache. Staff attempted to transfer resident to their wheelchair when they became unresponsive. Resident was placed back in bed and 911 was called. Resident passed away at the facility due to Major Neurocognitive Disorder (Dementia), Type unspecified without Behavioral Disturbances. Other significant factors in the case of death were listed as, Atrial Fibrillation, moderate protein calorie malnutrition, diastolic heart failure, chronic community acquired pneumonia.

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

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC9099 (FAS) - (06/04)

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