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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803241
Report Date: 02/15/2024
Date Signed: 02/15/2024 04:21:02 PM

Document Has Been Signed on 02/15/2024 04:21 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BROOKDALE CHANATEFACILITY NUMBER:
496803241
ADMINISTRATOR:LEDESMA, KATELYNFACILITY TYPE:
740
ADDRESS:3250 CHANATE RDTELEPHONE:
(707) 575-7503
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 140CENSUS: 82DATE:
02/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Resident Care Coordinator, Marissa Vargas, and Health and Wellness Director Heidi GallagherTIME COMPLETED:
02:30 PM
NARRATIVE
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At approximately 11:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Resident Services Coordinator, Marissa Vargas, and Business Office Manager, Danielle Oseguera. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 40 ambulatory, 100 non-ambulatory, which includes 20 bedridden for a total capacity of 140 residents. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPA was informed that there were currently 82 residents in care. LPA was also informed that there were 7 direct care staff members on-site.

LPA reviewed 5 staff files and 4 resident medications. Staff files were found to be well organized and thorough. During file review, LPA observed that two staff members did not have current first aid certificates. (See Technical Violation, LIC9102, H&S Code 1569.618(c)(3)). During medication review, LPA observed that one resident had three routine medications that were not documented or centrally stored as required (this deficiency has been cited, see LIC809D, 87465(h)(6)).

Facility's last fire/disaster drill was conducted January 2024. Facility's smoke detectors and sprinkler system were last inspected February 2024.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D, LIC9102 (Technical Violation), Plan of Corrections, and Appeal Rights discussed and provided to Business Office Director and Resident Care Coordinator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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Document Has Been Signed on 02/15/2024 04:21 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 02/15/2024 at 03:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE CHANATE
FACILITY NUMBER: 496803241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87645(h)(6)
87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observations made, the Licensee did not comply with the section cited above. Licensee did not ensure that a resident routine medications were documented and centrally stored as required. This poses a potential health, safety or personal rights risk to residents in care.
POC Due Date: 02/26/2024
Plan of Correction
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Licensee to conduct a OTC medication audit and ensure that all resident medications are documented appropriately per Title 22 regulations. Licensee to conduct an in-service training for all medication technicians reviewing how to centrally store medications. Training to include the following: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Proof of audit and in-service training to be submitted by POC due date of 02/26/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


LIC809 (FAS) - (06/04)
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