496803241-1-9-2025-21-AS-CCOO-DCRVGZ-20250109152620

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803241
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:26:34 PM

Document Has Been Signed on 01/09/2025 03:26 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/ DIRECTOR:	ALVARADO, ROBERT		FACILITY TYPE:	740
ADDRESS:	3250 CHANATE RD		TELEPHONE:	(707) 575-7503
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY: 140	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	01/09/2025
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:34 PM
MET WITH:	Robert Alvarado, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:43 PM

NARRATIVE

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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to amend 9009D issued on 12/27/24. LPA met with Robert Alvarado, Administrator.

On 12/27/24 LPA delivered complaint findings for complaint 21-AS-20241217154914. During this visit it was evidenced that an Incident Report relating to the substantiated allegation of the complaint was not received by CCL. Therefore, a citation was issued on the 9099D for deficiency of regulation 87211(a)(1)(D). However, this deficiency should not have been cited on a 9099D, rather it should have been cited on an 809D and 809 Case Management- deficiencies. The 9099D has been amended and the deficiency is now being cited on today’s case management-deficiencies (see 809D).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

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

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Christi Coppo	TELEPHONE: (707) 588-5054
	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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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Document Has Been Signed on 01/09/2025 03:26 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports...: (1) A written report shall be submitted to the licensing agency...for the resident within seven days of the occurrence of any of the events...(D) Any incident which threatens
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/10/2025
	Plan of Correction
1 2 3 4	Facility to submit LIC9098 self-certifying that facility will submit to CCL an Incident Report in compliance with regulation, by plan of correction due date. (Facility has already satisfied plan of correction, deficiency cleared)

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Christi Coppo	TELEPHONE: (707) 588-5054
	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC809 (FAS) - (06/04)

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