496803241-1-9-2025-21-AS-CCOO-DCRVJF-20250109152841

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803241
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:28:54 PM

Document Has Been Signed on 01/09/2025 03:28 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 - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:52 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 conduct a Case Management - Incident visit. LPA met with Robert Alvarado, Administrator.

On 12/23/24 facility submitted to CCL an Incident Report indicating that on 12/21/24 facility received reporting that resident (R1) was missing $500-$600 dollars in cash from their wallet. R1 reported to facility that they had last seen their money in their wallet when leaving the hospital on 12/19/24. R1 also reported the missing money to their family at an unknown date and time.

Per Incident Report submitted, upon receiving the report of missing money, the acting Admin was notified immediately by facility receptionist. R1's room was subsequently searched by Resident Care Coordinator (RCC); however, no money was recovered/found. Facility then notified Santa Rosa Police Department (SRPD) of the missing money and the issued case number was provided to CCL. The local ombudsman was also notified of the incident on 12/21/24. Additionally, facility RCC self reported the incident on a SOC341 to CCL on 12/23/24. No deficiencies cited for this incident.

On 1/6/25 CCL received an Incident Report regarding a medication error for resident (R2). R2 was given another resident's medications: Acyclovir, Metformin, and Pravastatin. Facility notified Emergency Medical Services (EMS) and R2 was taken to the hospital for evaluation. All required partied were notified by facility.

Continued on 809C...

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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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
	VISIT DATE: 01/09/2025

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Continued from 809...

Per Incident Report, R2 was diagnosed with non-toxic accidental ingestion and returned to the facility the same day. Resident placed on 72 hour alert charting (deficiency cited, 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 Licensee. 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.

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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/09/2025 03:28 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

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met by licensee in that another resident's medication was
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/17/2025
	Plan of Correction
1 2 3 4	Facility to conduct medication training and administer written medication test (as outlined in HSC 1569.69(a)(5)) with staff (S1), Med Tech responsible for the error. Facility to submit proof of training to CCL by plan of correction due date. **civil penaltiy assessed for repeat violation

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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